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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that it is medically necessary for the enrollee to receive 
SNF care. The Plan denied your request. The Plan says the criteria for admission to a SNF facility were not 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing needs. The enrollee does 
not have documented skilled therapy needs. The enrollee is consistently ambulating more than 100 feet and 
tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish 
a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care can, as a 
practical matter, be provided at a lower level of care. 
 
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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the FreeStyle Libra 2 sensors (CPT code K0553-KX-KF-CG) provided on April 11, 2022.

You asked the Plan to pay for the CGM. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore, the billed supply code cannot be verified.

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 CGM. Our physician reviewer found it is unclear why the CGM is needed for the enrollee or for the provider to determine appropriate therapy if the enrollee takes only metformin and there is no documented evidence of low blood glucose sugar (BGS) or labile BGS.

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 CGM have not been met. Therefore, we decided that the Plan does not have to pay for the FreeStyle Libra 2 sensors (CPT code K0553-KX-KF-CG) provided on April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 10, 2022.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says clinical records were not provided.

The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.

We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the ordering physician showing the physician's intent that the testing be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 10, 2022.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services (CPT code A0428HH) provided on April 2, 2022.

You asked the Plan to pay for the ambulance services. You say that the claim should be paid. The Plan denied your request. The Plan says that the services were not covered as billed.

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 did not provide the Explanation of Benefits to verify if the services were billed correctly. Therefore, we decided that the Plan has to pay for the ambulance services (CPT code A0428HH) provided on April 2, 2022. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the COVID-19 testing provided April 16, 2022, and April 27, 2022.

You asked the Plan to reimburse you for the COVID-19 testing. You say that you are appealing the denial of the COVID-19 tests administered at the San Francisco Airport and Munich Airport. The Plan denied your request. The Plan says Medicare does not cover non-diagnostic tests, testing done for public health surveillance purposes. Services are not covered under foreign benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal, the COVID-19 testing was requested solely for screening for traveling purposes. Medicare does not cover this test solely for screening for traveling purposes. Therefore, we decided that the Plan does not have to reimburse you for the COVID-19 testing provided April 16, 2022, and April 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission. 
 
You asked the Plan to pre-approve an inpatient admission. The Plan denied your request. The Plan says the 
criteria are not met because an intense level of care was not provided. 
 
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 an inpatient admission. Our reviewer 
says that the documentation does not support that the criteria for an inpatient admission are met in this case. 
Our physician reviewer found the enrollee has atrial fibrillation and is requesting hospital inpatient admission 
for a medication load and electrical cardioversion procedure. Recent notes describe the enrollee as clinically 
stable and hemodynamically stable with chronic atrial fibrillation without rapid ventricular response. Our 
reviewer found the enrollee is already on anticoagulation. The enrollee has diabetes which is controlled with 
medications. Our physician reviewer also found that there was no indication from provided documentation that 
this enrollee needs inpatient services that would be expected to last at least 2 midnights for the proposed 
procedure/treatments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve AminoBand.

You asked the Plan to pre-approve AminoBand. You say that AminoBand is medically necessary. The Plan denied your request. The Plan says AminoBand is not medically necessary.

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 pre-approve AminoBand. Our reviewer says that the requested AminoBand is not considered medically reasonable and necessary. Our physician reviewer found it is well established that this diabetic patient is suffering with a left foot wound status post-surgery. It is also well documented that the enrollee is suffering with significant/severe peripheral vascular disease. Medicare advises that they will not pay for items or services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. These treatments must be safe and effective, not mainly for the convenience of the patient or the physician, not experimental or investigational, and appropriate in that they should be furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member. In this particular case it is noted that the enrollee is suffering with severe lower extremity peripheral vascular disease. Adequate circulation is required in order for any graft to incorporate properly. The medical documentation supports that this enrollee has significant lower extremity peripheral vascular disease. It does not appear that the graft is medically appropriate for this enrollee as it will most likely not incorporate due to the peripheral vascular disease. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of AminoBand have not been met. Therefore, we decided that the Plan does not have to pre-approve AminoBand.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on April 22, 2022. 
 
You asked the Plan to pay for the testing services. You say that a modifier is not required. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that the testing at issue was not billed with a modifier suitable for 
payment. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on 
April 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator provided on June 5, 2021.

You asked the Plan to pay for the equipment. The Plan denied your request. The Plan says the claim was not submitted within the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the equipment was not filed until July 21, 2022. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator provided on June 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second genicular nerve block (64454).

You asked the Plan to pre-approve a genicular nerve block. You say that the enrollee is not a candidate for knee replacement surgery at this time. You say that the enrollee had 100% pain relief 6 hours after the first injection. You also say that a second injection is needed. The Plan denied your request. The Plan says the requested injection is not medically necessary.

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 pre-approve a genicular nerve block. Our reviewer says that the requested second genicular nerve block is not considered medically reasonable and necessary in this case. Our physician reviewer found the role of genicular nerve blocks in the treatment of osteoarthritis of the knee is considered experimental/ investigational. Therefore, the reviewer found that the requested genicular nerve block is not medically reasonable or necessary.

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 genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve a second genicular nerve block (64454).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76700) provided on July 5, 2022.

You asked the Plan to pay for procedure code 76700. You say that the claim should be paid. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for code 93976.

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 76700 is a column II code to column I code 93976. 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 the abdominal ultrasound (CPT code 76700) provided on July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 24, 2022.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285) provided on February 20, 2021.

You asked the Plan to pay for procedure code 99285. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare guidelines.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for procedure code 99285 was not filed until May 5, 2022. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) provided on February 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from  
February 28, 2022, to March 2, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford to 
pay this amount. The Plan denied your request. The Plan says this cost sharing was charged 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 for each time you are 
admitted to an acute care hospital, you pay $350 per day for days 1 to 5 and $0 after day 5. 
 
You have been asked to pay $700 ($350/day x 2 days = $700) for an inpatient hospital stay. This item/service 
falls within the inpatient hospital care 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 
an inpatient hospital stay from February 28, 2022, to March 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that due to fall risk, balance, and lack of independence it 
is not safe for you to remain home alone at this time. The Plan denied your request. The Plan says you do not 
meet the criteria for admission to a SNF and can be treated in a lower 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require skilled nursing or therapy services on a daily basis. Our reviewer 
found you do not meet the severity of illness or intensity of service criteria for 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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 18, 2022.

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 58999 is not supported.

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 58999 is unlisted procedure, female genital system (nonobstetrical).

We find that CPT code 58999 is not supported in the medical record. Specifically, the records show that a complete abdominal hysterectomy, salpingo-oophorectomy, lymphatic mapping, and limited lymphadenetomy were performed and there is a more appropriate code for the services. 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 surgical services rendered on January 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the gene panel testing provided on May 27, 2022. 
 
You asked the Plan to pay for the testing services. You say that the information validates medical necessity of 
the testing. The Plan denied your request. The Plan says that the claim was billed with an inconsistent date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We looked at the file and the rules. The records show that the enrollee has metastatic recurrent endometrial 
adenocarcinoma. The Plan has not shown that the specimen does not meet one of the exceptions for the billed 
date of service. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request. Based on this information, we decided that Medicare rules for 
coverage of the testing services have been met. Therefore, we decided that the Plan has to pay for the gene 
panel testing provided on May 27, 2022.  
 
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for hospital care (99239, 99233) provided from September 2, 2021, to September 3, 2021.

You asked the Plan to pay for hospital care. You say that this should be covered. The Plan denied your request. The Plan says that this claim is a duplicate of a previously paid claim and was correctly denied.

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. However, such denials may be appealed.

We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support the Plan's argument that the claim at issue is a duplicate. No documentation of a paid claim was included in the case file. Based on this information, we decided that Medicare rules for coverage of hospital care have been met. Therefore, we decided that the Plan has to pay for hospital care (99239, 99233) provided from September 2, 2021, to September 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 71250 billed for date of service June 28, 2022.

You asked the Plan to pay for procedure code 71250. You say that this should be paid for. The Plan denied your request. The Plan says payment for code 71250 is bundled into payment for code 71275.

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 71250 is a column II code to column I code 71275. 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 procedure code 71250 billed for date of service June 28, 2022.