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

We decided that the Plan does not have to pay for continuation of SNF services provided on
September 23, 2021.
You asked the Plan to pay for continuation of SNF services. You say that continuation of SNF services is
medically necessary. The Plan denied your request. The Plan says continuation of SNF services is not
medically necessary.
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 pay for continuation of SNF services. Our reviewer
says that daily skilled services are not medically necessary. Our physician reviewer found that 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 beyond the last
covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or
other skilled nursing SNF need. 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 are noted to have reached maximum functional capacity per
the therapy notes. You do not require skilled nursing or skilled therapy services (or a combination of these
services) on a "daily basis" in a SNF beyond the last covered date. As a practical matter, you do not require the
necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the
Plan does not have to pay for continuation of SNF services provided on September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography services (75726-59-76, 75774-59, 75774-59-76 and 75726-59) provided on June 8, 2021.
  
You asked the Plan to pay for the angiography services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 75726, 75774 and 37243.
  
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 angiography services. Our reviewer says that 75726 59,  75726-59-76, 75774-59, and 75774-59-76 are all inclusive to CPT 37243. Our reviewer found per NCCI edits, an acceptable modifier is allowed in order to unbundle these services, providing the medical records support the use of the modifier.  However, in this case, the medical documentation submitted does not include sufficient documentation to validate the use of a 59 modifier on 75726 59,  75726-59-76, 75774-59, and  75774-59-76 to unbundle services from CPT 37243, therefore, no additional reimbursement is allowed.

 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 angiography services have not been met. Therefore, we decided that the Plan does not have to pay for the angiography services (75726-59-76, 75774-59, 75774-59-76 and 75726-59) provided on June 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services 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 the records do not support the need for a skilled nurse to make more visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care 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 pre-approve the services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does
not have documented skilled nursing needs, such as IVs, complex wound care, or new ostomy. As such, the
requested ongoing home health skilled nursing services are 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve home health services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D7953), surgical extractions 
(D7210), drug injection (D9610) and gum surgery (D4266).

You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says they have agreed to pre-approve the implant placements for teeth #2 
and #4 and will issue partial payment for these services up to your benefit allowance. However, the projected 
cost of these services will exceed your annual maximum for dental care and will not be covered.

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. The Plan can pay a maximum 
of $3,000 for supplemental dental services per calendar year.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services provided in excess of 
the Plan's $3,000 annual maximum will not be covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve a bone replacement graft (D7953), surgical extractions (D7210), drug injection 
(D9610) and gum surgery (D4266). Please note that this decision was made using your 2021 dental benefits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
You asked the Plan to pre-approve additional mileage for routine transportation. You say that the enrollee
needs to get to provider's office and has no transportation. The Plan denied your request. The Plan says the
enrollee's benefit only allows 60 one-way trips with each one-way trip not exceeding 75 miles of driving
distance.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 75 miles.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Specifically, the provider is
located 138 miles away from the enrollee's residence. The Plan only covers distances up to 75 miles.
Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation
(A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 and 99191, the autologous blood or component coded 86891, and the red blood cells coded P9022 provided on March 1, 2021.  You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger services, the autologous blood or component, and the red blood cells. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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.  We find that CPT codes 99190, 99191, 86891, and P9022 are not supported in the medical record. Specifically, the enrollee was inpatient for this date of service. This means that these services are included in the payment made to the facility. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump with oxygenator or heat exchanger services, the autologous blood or component, and the red blood cells have not been met. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 and 99191, the autologous blood or component coded 86891, and the red blood cells coded P9022 provided on March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one (1) occupational therapy (OT) visit (G0152).

You asked the Plan to pre-approve (1) OT visit. You say that the requested OT visit is medically necessary.
The Plan denied your request. The Plan says the requested OT visit does not meet criteria.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy.

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 (1) OT visit. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has not made significant progress or meaningful 
functional gains and has reached her maximum potential. The enrollee has requested for occupational therapy 
services to be discontinued as she does not feel that she is benefiting from the services. The enrollee was given 
a home exercise program (HEP) and discharged from OT per her request.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of (1) OT visit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve one (1) occupational therapy (OT) visit (G0152).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640 provided on October 2, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 find that CPT codes 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a Skilled Nursing Facility, place of service 31. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640 provided on October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for eye refractions (92015) provided October 6, 2021.  You asked the Plan to pay for the eye refractions. You say that this service should be covered. The Plan denied your request. The Plan says the services were not part of an annual vision screening and were not provided by a contract provider.  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 obtained from a contract provider as part of a routine annual screening.  We looked at the file and the Plan's rules. The services were not provided by a plan contract provider and were a medical exam and not a routine screening. Based on this information, we decided that the Plan's rules for coverage of the eye refractions have not been met. Therefore, we decided that the Plan does not have to pay for eye refractions (92015) provided October 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthetic agent injection (64450) provided on June 30, 2021.  You asked the Plan to pay for the anesthetic agent injection (64450). You say that code 64450 was billed with modifier 59 to indicate a separate service. You say that the medical records support the code performed was medically necessary and payment should be reconsidered. The Plan denied your request. The Plan says CPT code 64450 is included in CPT code 01480 and cannot be separately reimbursed.  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 64450 is injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch.  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 anesthetic agent injection (64450). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. An epidural or peripheral nerve block that provides intraoperative pain management is included the anesthesia code and is not separately reportable. Our reviewer found that the anesthesia report does not support a post anesthetic injection requested by the operating physician.   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 anesthetic agent (64450) have not been met. Therefore, we decided that the Plan does not have to pay for the anesthetic agent injection (64450) provided on June 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently febrile, tachypneic, and dyspneic, requiring ongoing acute
care services. The enrollee continues to receive acute care services, and these have not been denied. The
medical record does not indicate that the enrollee requires services that he is not currently receiving but that
would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk in bathtub.
You asked the Plan to pre-approve the tub. You say that you are unable to use the bath due to back and hip
issues. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a walk in bathtub.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided March 2, 2021, to March 15,
2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary.
The Plan denied your request. The Plan says that coverage criteria has not been met.
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 supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably
expected that the patient's necessary hospital care (including earlier emergency 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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided March 2, 2021, to March 15, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to an LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee was admitted with altered mental status due to hypoxic respiratory failure from streptococcal pneumonia and found to have acute kidney injury.
The record indicates that the enrollee is improving but still requires ongoing acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam (92015 and 92004) provided
on August 9, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that you would like reconsideration
because you believe the provider submitted this claim twice to different plans and would like your benefit
reinstated. The Plan denied your request. The Plan says the copayment applied to this claim is correct.
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 Vision Care.
You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the Vision 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 the eye exam (92015 and 92004)
provided on August 9, 2021.
Your complaint about the provider submitted an additional claim to other insurance is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September
23, 2021.
You asked the Plan to pay for the dental service. You say that the provider did not inform you that the exam
was not covered. You say that had you known, you would have refused the service. You also say that you
cannot afford to pay this bill. The Plan denied your request. The Plan says limited oral evaluation is not listed
as a covered service.
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, the limited oral evaluation is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
limited oral evaluation (D0140) provided on September 23, 2021.