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

 We decided that the Plan does not have to pay for the mass spectrometry rendered on June 16, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 83789 (mass spectrometry) and 80307 (presumptive drug testing). Code 83789 is a column II code with a modifier indicator of 1 when billed with column I code 80307. Code 83789 was not billed with an appropriate modifier to allow for separate payment. The file does not support the -59 modifier as a separate and distinct procedure. Therefore, we decided that the Plan does not have to pay for the mass spectrometry rendered on June 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from March 2, 2020, through March 4, 2020, and billed with a Patient Driven Payment Model (PDPM) Score of MHMC1.  You asked the Plan to pay for the SNF services as billed. You say that you do not agree with the Plan's reprocessed claim. The Plan denied your request. The Plan says the claim has been billed incorrectly based on Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that you are required to complete the Minimum Data Set (MDS) for reimbursement under skilled nursing facility prospective payment system (SNF PPS).          We looked at the file and Medicare rules. In this case, no MDS was completed by the provider according to the documentation provided. Based on this information, we decided that Medicare rules for coverage of the SNF services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from March 2, 2020, through March 4, 2020, and billed with a Patient Driven Payment Model (PDPM) Score of MHMC1.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rotator cuff repair rendered on July 15, 2021.  

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 23412 is not separately payable.  

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  

The provider submitted a claim for procedure codes 23412 and 23472. Code 23412 is a column II code with a modifier indicator of 1 when billed with column I code 23472. Code 23412 was not billed with an appropriate modifier to allow for separate payment. The file does not support the -59 modifier as a separate and distinct procedure. Therefore, we decided that the Plan does not have to pay for the rotator cuff repair rendered on July 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a single-photon emission computed tomography test (SPECT) for the enrollee.  You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your request. The Plan says this request does not meet the criteria.  The Plan must follow Medicare rules. Medicare rules say that SPECT scans are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the test. Our reviewer says that the requested test is not medically reasonable or necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has shortness of breath from smoking. The record does not document any cardiac symptoms or electrocardiogram. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  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 test have not been met. Therefore, we decided that the Plan does not have to pre-approve a single-photon emission computed tomography test (SPECT) for the enrollee.
Appeal type: Testing
Decision: Favorable

 We decided that the Plan has to waive the copayment for remote cardiac monitoring provided on June 18, 2021.  You asked the Plan to waive the copayment for the remote cardiac monitoring. You say that the procedure was coded incorrectly and you should not have any copayments. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for diagnostic procedures and tests.   The Plan says you must pay a $35.18 copayment for the remote cardiac monitoring. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the remote cardiac monitoring. Therefore, we decided that the Plan has to waive the copayment for remote cardiac monitoring provided on June 18, 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Stelara.  You asked the Plan to pre-approve Stelara. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the medical benefit.  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 Stelara.     Benefits for Stelara 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the 3D rendering with interpretation and report rendered on April 12, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 76376 (3D rendering with interpretation and report) and 74174 (computed tomography angiography of the abdomen/pelvis). Code 76376 is a column II code with a modifier indicator of 1 when billed with column I code 74174. Code 76376 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 3D rendering with interpretation and report rendered on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic manipulative treatment (98941), an office visit (99213) and electrical stimulation (G0283) provided on July 21, 2021, to August 20, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for chiropractic manipulative treatment, an office visit and electrical stimulation. You say that you requested an authorization and assumed it was alright to go ahead with treatment. The Plan denied your request. The Plan says it was determined that there are no records of prior authorization being obtained from the member's primary care provider for these services. The Plan also says that you must have an approval from the Plan before getting medical services or items from a specialist, an out-of-network provider, or certain other providers. The Plan also says there were in-network providers available.    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 chiropractic manipulative treatment (98941), an office visit (99213) and electrical stimulation (G0283) provided on July 21, 2021, to August 20, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the skin debridement procedure you had at an outpatient hospital facility on September 30, 2021.  

You asked the Plan to waive the copayment for the skin debridement procedure. You say that you do not think you should have to pay this amount when you only had one service on your leg. 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 $250 copayment for surgical services in an outpatient hospital.   

You have been asked to pay a $250 copayment for the skin debridement procedure. Skin debridement is considered a surgical service. 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 skin debridement procedure you had at an outpatient hospital facility on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injections (62320) provided September 20, 2021.  You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. Insufficient clinical documentation was provided to support the code billed. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided September 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.  You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not meet criteria.  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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, including insulin and had stable vital signs.  The enrollee was at a total assist to dependent level with bed mobility and transfers. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a custom-fabricated elbow/wrist/hand/finger orthosis 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 this is considered experimental and investigational.  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 there is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity paralysis/paresis from conditions such as spinal cord injury, stroke, or other neuromuscular/neurological disease or injury.    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 a custom-fabricated elbow/wrist/hand/finger orthosis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the autologous blood or component collection and storage (86891), washed red blood cells (P9022) and the assembly and operation of a pump (99190 and 99191) provided on July 7, 2021.  You asked the Plan to pay for the autologous blood or component collection and storage, washed red blood cells and assembly and operation of a pump. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for these services is included in the payment to the facility.  The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the autologous blood or component collection and storage, washed red blood cells and assembly and operation of a pump have not been met. Specifically, the documentation indicates that the member was registered inpatient on the billed date of service. Payment for these services is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the autologous blood or component collection and storage (86891), washed red blood cells (P9022) and the assembly and operation of a pump (99190 and 99191) provided on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for hospital observation care provided on November 30, 2021.  You asked the Plan to waive the copayment for the hospital observation care. You say that the stay was medically necessary and you feel that you should not be responsible for the 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 an $80 copayment for outpatient hospital observation services.  You have been asked to pay an $80 copayment for the hospital observation care. The hospital observation care falls within the Outpatient Hospital Observation 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 hospital observation care provided on November 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.  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 undergoing treatment at an acute care hospital (ACH) for renal failure and gastrointestinal bleeding. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.  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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Euflexxa (J7323).  You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says although the enrollee has done water care, the enrollee has not failed three months of exercise care. The Plan also says that the medical need for Euflexxa injections were not met.  The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary when the patient has failed at least three months of conservative therapy, such as but not limited to home exercise program, education, weight loss, physical therapy if indicated.  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 Euflexxa. Our reviewer says that Euflexxa does not meet the coverage criteria. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee meets all of the indication criteria for Euflexxa as listed in the Local Coverage Determination (LCD) L35427: Hyaluronan Acid Therapies for Osteoarthritis of the Knee. Our reviewer also found that the records do not document that the enrollee has failed at least three months of conservative therapy with a home exercise program, education, weight loss or physical therapy.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on July 22, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to issue reimbursement for the wheelchair, with detachable arms, and swing away detachable footrests (E1140) purchased from the out-of-network (OON) provider on July 10, 2021.  You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item was purchased from an out of network provider, without prior authorization.  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 issue reimbursement for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to issue reimbursement for this item.  Therefore, we decided that the Plan does not have to issue reimbursement for the wheelchair, with detachable arms, and swing away detachable footrests (E1140) purchased from the out-of-network (OON) provider on July 10, 2021.