Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pre-approve an inpatient hospital admission.  You asked the Plan to pre-approve acute inpatient hospital care. You say that an inpatient hospital admission is medically necessary due to the enrollee's comorbidities. The Plan denied your request. The Plan says that the enrollee's care can be provided without an inpatient stay following the surgical procedure.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our physician reviewer found at the time of the request for an inpatient admission, the requesting physician reasonably expected that the enrollee's necessary hospital care would span two midnights. The enrollee is being treated for bilateral primary osteoarthritis of knee. He is planned to undergo a right total knee replacement. Past medical history was positive for paroxysmal atrial fibrillation, coronary disease with history of bypass grafts. The January 28, 2022, preoperative risk assessment documented he would be considered moderate risk for cardiovascular complications. Detailed documentation is evident for significant past and/or current medical history that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient stay.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve an inpatient hospital admission.         If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the breast implant services provided on May 19, 2021.  You asked the Plan to pay for the billed services. You say that the documentation supports the use of the codes. The Plan denied your request. The Plan says the code cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.    In this case, the CPT Code Manual definition of code 19340 is insertion of breast implant on same day of mastectomy (ie, immediate). We find that CPT code 19340 is not supported in the medical record. The records provided do not indicate a mastectomy was provided on the date of service at issue. Based on this information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the breast implant services provided on May 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay in full for the periodic oral evaluation (D0120) and bitewing x-rays (D0274) provided on September 20, 2021 by an out-of-network (OON) provider.    You asked the Plan to pay in full for the periodic oral evaluation and bitewing x-rays. You say that you contacted the customer service department and were told you were allowed 3 cleanings in a year. You also say that you had been going to this in-network dentist office for almost 2 years and on this visit, you saw a different dentist, but you were not informed by the dentist that this treating provider was not in the Plan's network. The Plan denied your request. The Plan says this claim was processed and the OON member liability was applied correctly. The Plan also says that since the treating provider is OON, the Plan pays according to a maximum allowable fee schedule, and you are responsible for all fees in excess of this amount from the billed amount.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference between the billed amount and allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan does not have to pay in full for the periodic oral evaluation (D0120) and bitewing x-rays (D0274) provided on September 20, 2021 by an out-of-network (OON) provider.   Please Note: The Plan has confirmed with your provider that the OON charges for the periodic oral evaluation (D0120) and bitewing x-rays (D0274) are being written off and you have been issued a new billing statement. Please contact the Plan or the provider's office for any questions regarding this.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a simple extraction (D7140) and face bone graft (21210) provided on July 16, 2021.  You asked the Plan to pay for a simple extraction and face bone graft. You say that you were told by the surgeon that this was a medical procedure, not a dental procedure. The Plan denied your request. The Plan says these services are not eligible for coverage under the medical benefits.  The Plan must follow Medicare rules. Medicare rules say that Medicare will not pay for dental services.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for simple extraction and face bone graft. Our reviewer says that the cyst appears to be of dental origins. As the cyst was directly associated with a tooth, the procedure was essentially dental in nature.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of simple extraction and face bone graft have not been met. Therefore, we decided that the Plan does not have to pay for a simple extraction (D7140) and face bone graft (21210) provided on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on January 26, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.      We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on January 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy (PT) visits (97110) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve PT visits. You say that you would like to have your PT done closer to your home just in case something happens. The Plan denied your request. The Plan says there are in-network providers available for these services.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy (PT) visits (97110) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel.  You asked the Plan to pre-approve a targeted genomic sequence analysis panel. You say that the records provided support the need for the requested testing. The Plan denied your request. The Plan says the requested testing is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that genetic testing is covered for certain clinical indications and when medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a targeted genomic sequence analysis panel. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the guidelines do not support the clinical utility of broad genomic profiling for a hematological malignancy work-up.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction (92015) provided on September 28, 2021. You asked the Plan to pay for an eye refraction. You say that you had an eye exam to check if your current prescription for your glasses were sufficient and to check for cataracts. The Plan denied your request. The Plan says the requested service is not a covered benefit since it was a medical vision exam to check for age-related cataracts in the right eye. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when it is performed as a routine screening by a participating provider.  We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on September 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal angiography rendered on August 4, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 75726 is not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.     The provider submitted a claim for procedure codes 75726 (abdominal angiography) and 37243 (vascular embolization). Code 75726 is a column II code with a modifier indicator of 1 when billed with column I code 37243. Code 75726 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the abdominal angiography rendered on August 4, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for emergency department services (procedure code 99282) provided to the enrollee on May 26, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a modifier was not billed on the claim to represent the services as separate or distinct.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 99282 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity."  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were n Our reviewer found the medical and billing records indicate the enrollee was seen twice on May 26, 2021 by different emergency service providers. When a patient is seen twice in the same day by either the same provider or provider group, only one evaluation and management service is allowed to be reported, unless the evaluation and management services are unrelated. Should that be the case, the National Correct Coding Initiative (NCCI) allows for an appropriate modifier to be appended to the evaluation and management services code to identify it as a separate and distinct service. In this case, CPT 99282 is considered incidental to CPT 99285, which was performed on May 26, 2021 as well. When CPT 99282 was submitted to the health plan, it was submitted without an appropriate modifier to identify it as a distinct, separate service from 99285, therefore, Medicare rules have not been met to allow for reimbursement consideration.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for emergency department services (procedure code 99282) provided to the enrollee on May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Transcatheter Aortic Valve Replacement (TAVR) and associated Computed Tomography (CT) Imaging (74174, 71275, 33361, 75574).  You asked the Plan to pre-approve the TAVR procedure and related imaging. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that CT imaging and Transcatheter Aortic Valve Replacement are covered when medically necessary based on the provided clinical documentation. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the TAVR procedure and related imaging. Our reviewer says that the requested procedures are not medically necessary. Our physician reviewer found the enrollee was thought to have severe aortic stenosis by echocardiography, but cardiac catheterization showed no significant aortic stenosis. As a result, at this time the requested TAVR procedure along with CT imaging would not be considered medically necessary in this patient's clinical management.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the TAVR procedure and related imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve a Transcatheter Aortic Valve Replacement (TAVR) and associated Computed Tomography (CT) Imaging (74174, 71275, 33361, 75574).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Bystolic.  You asked the Plan to pre-approve Bystolic. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee does not have coverage for outpatient prescription drugs under this contract. The Plan says that the enrollee may have a separate commercial pharmacy benefit or Medicare Part D benefit managed by another carrier.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Bystolic.   Benefits for Bystolic may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for wound debridement (11042) provided on  December 24, 2020.   You asked the Plan to pay for wound debridement (11042). The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 11042 is a column II code to column I code 15271. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for wound debridement (11042) provided on December 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you need IRF care given your current condition. You say that 30 days is too long without rehabilitation, and it will harm you if you do not get rehabilitation soon. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could receive the care needed in another setting.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee admitted for surgical repair of a hip fracture after a fall, a coronavirus infection, and urinary tract infection. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a clinic visit (G0463) provided on October 5, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a clinic visit. You say that the enrollee was previously treated by this provider. The Plan denied your request. The Plan says this was not authorized.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a clinic visit (G0463) provided on October 5, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on March 1, 2021.  You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are included in the dialysis rate. The Plan denied your request. The Plan says the testing is the responsibility of the dialysis center.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 1, 2021.