Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's needs can be provided at an alternative level of care.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from September 9, 2020 to September 12, 2020.  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 submitted records do not support the billing of diagnosis code J96.21.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with diagnosis code J96.21 (acute and chronic respiratory failure with hypercapnia). 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 these services. Our reviewer says that the submitted records do not support the billing of diagnosis code J96.21. Our physician reviewer found the records are incomplete to support significant, prolonged tachypnea following acute treatment in the emergency department. There are no signs or symptoms of acute respiratory decompensation or increased work of breathing such as accessory muscle use, sternal retractions, paradoxical respirations, or altered mental status. No evidence was located in the records available to reflect resource utilization of high flow supplemental oxygen, monitoring of arterial or venous blood gas results or noninvasive/invasive ventilatory assistance during the encounter. The billing of diagnosis code J96.21 is therefore not supported.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from September 9, 2020 to September 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on August 18, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that you were supposed to get and head/neck scan instead of just a head CT scan.  You also say that you have two insurance carriers. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for advanced imaging services.   You have been asked to pay a $200 copayment for the CT scan. The CT scan falls within the advanced imaging services benefit category. This copayment applies regardless of the reason for the test. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on August 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient care provided to the enrollee from March 3, 2019, to March 13, 2019.  You asked the Plan to pay for inpatient services. You say that this claim should be paid as the documentation supports the services billed. The Plan denied your request. The Plan says the records provided do not support the diagnosis code billed.    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.  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 this claim. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the documentation shows the provider billed a principal diagnosis code I49.5 (sick sinus syndrome) stating this was a valid principal diagnosis for the hospitalization. The provider documentation in the history and physical states that the enrollee had a chief complaint of right arm and leg weakness and a diagnosis of "recurrent cerebral embolus on Apixaban." The inpatient admission order states a diagnosis of "stroke". The discharge summary also states the enrollee presented with "dizziness right sided weakness, feeling off balance, and with gait instability 2/2 to L precentral gyrus infarct on imaging." The review has determined that the documentation does not show that the diagnoses billed were supported by the records.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from March 3, 2019, to March 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair with battery, headrest, custom seat cushion, joystick and harness.  You asked the Plan to pre-approve a group 3 power wheelchair with battery, headrest, custom seat cushion, joystick and harness. You say that the items are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for the wheelchair or accessories.  The Plan follows Medicare rules. Medicare rules say that all of the basic criteria (A-C) in the Medicare Rules section must be met for a power mobility device.   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 group 3 power wheelchair with battery, headrest, custom seat cushion, joystick and harness. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does not meet the criteria for the power wheelchair or accessories.  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 group 3 power wheelchair with battery, headrest, custom seat cushion, joystick and harness have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with battery, headrest, custom seat cushion, joystick and harness.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the exploration of spinal surgery (22830) provided on April 26, 2021.  You asked the Plan to pay for code 22830. You say that the medical records support the billing of code 22830-59 provided on April 26, 2021. The Plan denied your request. The Plan says the medical records do not support the billing of code 22830-59 provided on April 26, 2021.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    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 code 22830. Our reviewer says that the medical records do not support the billing of code 22830-59 provided on April 26, 2021.  Our physician reviewer found the code 22830 cannot be billed on a segment in which a fusion code is also used. Also, the exploration is not appropriately supported in the records.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 22830 have not been met. Therefore, we decided that the Plan does not have to pay for the exploration of spinal surgery (22830) provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Supartz FX to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve Supartz FX to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.  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. 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 Supartz FX to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for the services (93042) provided on May 3, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this code is not payable with code 99291.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan argues that an NCCI edit exists between codes 99291 and 93042. However, an NCCI edit pair search does not show that an edit exists between code 99291 and code 93042. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (93042) provided on May 3, 2021.   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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for advance care planning (99497) provided October 9, 2020 to October 13, 2020.  You asked the Plan to pay for the advance care planning. You say that you have attached supporting documentation and ask for review of all information submitted and reconsideration of the medical claim for payment. The Plan denied your request. The Plan says this code is not separately payable.  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 the advance care planning is a column II code to column I code 99291. 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 advance care planning (99497) provided October 9, 2020 to October 13, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.    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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal that the enrollee requires treatment at this point in a SNF as the enrollee continues to require medical management in acute care. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on June 15, 2020.  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 claim is a duplicate.  The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.    We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 26, 2021.  You asked the Plan to waive the copayment for a specialist office visit. You say that when you see the cardiologist, you see a nurse practitioner. You say that you are being billed a specialist copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each in-network specialist visit.   You have been asked to pay a $40 copayment for the specialist office visit. The medical records show you received services from a cardiology specialist. Specialty office visits fall within the Physician/Practitioner Services Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Adjacent tissue transfer or rearrangement (14302) provided on January 28, 2021.  You asked the Plan to pay for code 14302. You say that the medical records support the billing of code 14302. The Plan denied your request. The Plan says the medical records do not support the billing of code 14302.  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 14302 is Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure).  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 code 14302. Our reviewer says that the medical records do not support the billing of code 14302. Our reviewer found the record indicates that the enrollee underwent a procedure. The procedure is described as an advancement.  The record does not indicate that a transfer or arrangement was performed. The elements of the coverage criteria are not satisfied.  The requested service is not recommended.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 14302 have not been met. Therefore, we decided that the Plan does not have to pay for the Adjacent tissue transfer or rearrangement (14302) provided on January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pharmacogenomic profile (81226, 81240, 81241, 81220, 81227, 81230, 81291 and 81335) provided on March 15, 2021.  You asked the Plan to pay for the pharmacogenomic profile. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services have not been billed correctly.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.     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 the pharmacogenomic profile. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found it has not been demonstrated that the testing would impact the management and outcome of this enrollee's condition.  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 pharmacogenomic profile have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomic profile (81226, 81240, 81241, 81220, 81227, 81230, 81291 and 81335) provided on March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the nasal interface mask (A7034) provided on June 28, 2021.  You asked the Plan to pay for code A7034. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the nasal interface mask (A7034) provided on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on March 12, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.  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 the laboratory services provided on March 12, 2021 by an out-of-network (OON) provider.