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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 11, 2020, to June 12, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the rendered services were medically appropriate. You also say that proper payment has not been received. The Plan denied your request. The Plan says the documentation does not indicate there was an expectation of a 2 midnight stay.

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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided documentation indicates that the enrollee was admitted to telemetry level of care, with orders for neurovascular checks every four hours and a computed tomography (CAT) scan of the brain without contrast the next morning. The reviewer found that the provided documentation did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

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 not been met. Specifically, the file does not show that the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 11, 2020, to June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment from $250 to $25 for the dressings and/or debridement of partial-thickness burns, initial or subsequent (16020) provided on January 29, 2021.

You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $250 copayment for each visit to a hospital outpatient surgical department.

You have been asked to pay a $250 copayment for the hospital outpatient surgical department visit provided. 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 adjust the copayment from $250 to $25 for the dressings and/or debridement of partial-thickness burns, initial or subsequent (16020) provided on January 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95886), neuromuscular junction testing (95937) and electroencephalogram (95937) provided on April 27, 2021.

You asked the Plan to pay for the needle electromyography, neuromuscular junction testing and electroencephalogram. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.

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 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 needle electromyography, neuromuscular junction testing and electroencephalogram. Our reviewer says that CPT codes 95886, 95955 and 95937 do not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided does not include documentation to validate a Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) being performed on April 27, 2021. Pedicle screw stimulations are not baseline nerve conduction studies.

The medical records provided indicate a real time EEG was performed, which is not covered under CPT code 95955, therefore this service cannot be verified. 

The medical records indicate Train of Four testing was performed. Train of Four testing is not included in the code description for CPT 95937. There is no specific code used to represent Train of Four testing as it is inclusive to Intraoperative Neuromonitoring (IONM), whether the IONM is primarily Electromyography based or maximum expiratory pressure based. Therefore, 95937 cannot be verified. 

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 needle electromyography, neuromuscular junction testing and electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95886), neuromuscular junction testing (95937) and electroencephalogram (95937) provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve Intracept. You say that you need to have this procedure to stop the pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there are not enough studies to show that Intracept is safe and effective.

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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (27096) provided on March 22, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed without an appropriate modifier.

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 find that CPT code 27096 is not supported in the medical record. Specifically, code 27096 is assigned a bilateral indicator of 1. This means that an anatomical modifier must be used when appropriate. In this case, an appropriate anatomical modifier was not used. 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 the services (27096) provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (64635, 64636) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says according to the clinical documentation, there have been two lumbar medial branch block injections in the last 12 months.

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee had lumbar medial branch blocks on right side on 3/1/21, the left side on 3/8/21, and bilateral on 9/2/21. These blocks are limited to no more than two sessions per region, per rolling 12 months. The benefit has been exhausted. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (64635, 64636) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Privigen.

You asked the Plan to pre-approve Privigen. You say that this drug is necessary for the enrollee's treatment.
The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the
enrollee is participating in a clinical trial and therefore the Plan is not responsible for coverage of this drug.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.

In this case, you asked the Plan to pre-approve Privigen as part of a clinical trial. The Plan does not cover
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve
use of Privigen.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on October 29, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is not payable for these services.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuroablation services.

You asked the Plan to pre-approve neuroablation services. You say that the nerve block was requested as a procedure being done preoperatively to help with pain control and decrease the pain medication usage after her knee arthroplasty. The Plan denied your request. The Plan says medical studies do not show that the requested procedure works better than others for the enrollee's condition.

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 neuroablation services. Our reviewer says that the neuroablation services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has right knee osteoarthritis and is having a knee arthroplasty. The request is for cryoablation of the right genicular nerves to provide post-operative analgesia. This is considered an experimental/ investigational procedure that is the subject of ongoing clinical trials.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuroablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve neuroablation services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a presbyopia-correcting function of an intraocular lens (V2788) provided on May 4, 2021.

You asked the Plan to pay for a presbyopia-correcting function of an intraocular lens. You say that this should be at least partially covered. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare doesn't pay physician and facility services for insertion, adjustment, or other subsequent presbyopia-correcting intraocular lens functionality treatments. 

We looked at the file and Medicare rules. A presbyopia-correcting function of an intraocular lens is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a presbyopia-correcting function of an intraocular lens (V2788) provided on May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 23, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on March 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility care after December 14, 2021.

You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary. The Plan denied your request. The Plan says SNF care is not medically reasonable and necessary beyond the approved dates in question.

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 while there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, 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 skilled nursing facility care after December 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.

You asked the Plan to pre-approve Trulicity. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Trulicity.

Benefits for Trulicity 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81206, 81207, G0452) provided on March 31, 2021.

You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says there is not documentation this was ordered.

The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician. 

We looked at the file and Medicare rules. The submitted records do not contain a physician's order for the testing at issue. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81206, 81207, G0452) provided on March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.

You asked the Plan to pre-approve the concentrator. You say that this is medically necessary, as the current tanks are not rechargeable. The Plan denied your request. The Plan says there is no medical need for this item.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.

To qualify for home oxygen, the patient must meet one of the following blood gas levels:

1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 

2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 

3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 

4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.

For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 

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 concentrator. Our reviewer says that the requested concentrator is not medically reasonable or necessary. Our physician reviewer found the enrollee has a portable oxygen tank. In this case, it has not been demonstrated that the requested portable oxygen concentrator is medically reasonable and necessary for the enrollee. 

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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (64494) provided on June 22, 201.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE value has been exceeded.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 the services (64494) provided on June 22, 201.
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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as 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.