Persius/hicric huggingface dataset:
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 you need inpatient rehabilitation. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.  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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  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.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (G0483) provided on May 19, 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 drug testing services (G0483) provided on May 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the patient needs extended care for PTM and wound care and management. She needs to be moved out of acute care hospital to extended care to improve health. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of admission to a LTACH does not meet the requirements for approval.  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 that the enrollee was admitted with biliary sepsis due to choledocholithiasis in the setting of chronic total parenteral nutrition for short gut syndrome. The record indicates that the enrollee is at her baseline status. 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 she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left stab phlebectomy.  You asked the Plan to pre-approve a left stab phlebectomy. You say that this is medically necessary The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that the phlebectomy is subject to the criteria listed 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 a left stab phlebectomy. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found that the documentation does not meet coverage criteria and does not support the medical necessity of stab phlebectomy.  Apparently left greater saphenous vein ablation was approved.  Coverage criteria require that the patient be reevaluated after at least a 6-week period in the absence of significant truncal reflux.  As the reflux has not yet been addressed, this period has not passed.  Additionally, coverage criteria require that the diameter of the tributary veins slated for phlebectomy be documented to be greater than 4 mm in diameter.  This is not documented. The criteria for coverage have not been met.  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 left stab phlebectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a left stab phlebectomy.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on October 11, 2021.  You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you were told by the staff that you would not owe a copayment for a second mammogram. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for diagnostic procedures and tests provided in a specialist's office.  The medical records show that you received a diagnostic mammogram on October 11, 2021, due to abnormal findings found during a mammogram screening. Therefore, you are responsible to pay the $35 copayment.    You have been asked to pay a $35 copayment for a diagnostic mammogram. A diagnostic mammogram falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on August 3, 2021.  You asked the Plan to pay for the testing services. You say that the test is used to determine treatment. The Plan denied your request. The Plan says the requirements have not been met.  The Plan must follow Medicare rules. Medicare rules say that BRCA genetic testing is only covered under certain medical indications.   We looked at the file and Medicare rules. The records do not indicate that the enrollee has a relative with breast, ovarian, or prostate cancer. The records do not show that the enrollee is of an ethnicity associated with a higher mutation frequency. 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 genetic testing provided on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 2, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.        Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for IV therapy and does not have to waive the coinsurance for a Medicare Part B drug provided on August 10, 2021.

You asked the Plan to waive the copayments for IV therapy and to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for outpatient hospital services and 20% coinsurance for Medicare Part B prescription drugs.

You received IV therapy at an outpatient hospital facility on August 10, 2021. Therefore, you are responsible to pay the $100 copayment. 

You received a Medicare Part B drug on August 10, 2021. Therefore, you are responsible to pay $100.42, which is less than the 20% coinsurance. 

The total amount you owe is: $200.42.

You have been asked to pay the total amount of $200.42 for IV therapy and a Medicare Part B drug. IV therapy falls within the outpatient hospital services benefit category. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 copayments for IV therapy and does not have to waive the coinsurance for a Medicare Part B drug provided on August 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head rendered on September 25, 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 70544 (MRA head) and 70551 (magnetic resonance imaging, brain stem). Code 70544 is a column II code with a modifier indicator of 1 when billed with column I code 70551. Code 70544 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 magnetic resonance angiography (MRA) of the head rendered on September 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by an out-of-network provider on October 8, 2021.  You asked the Plan to pay for a comprehensive oral evaluation. You say that you do not feel like you should have to pay for the first visit because the dentist did not help. The Plan denied your request. The Plan says the benefit limit for a comprehensive oral evaluation has already been exhausted.  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 covers one comprehensive oral evaluation per three calendar years.   We looked at the file and Medicare rules. Evidence was provided to show that a comprehensive oral evaluation was provided on September 22, 2021.  Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by an out-of-network provider on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services provided on March 26, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate payment is made.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the SelectMDX testing (CPT code 81479) provided to the enrollee on September 29, 2021.  You asked the Plan to pay for the laboratory testing. You say that the test was requested directly from the treating physician who makes the professional determination of diagnosis and medical necessity to successfully treat the patient. The Plan denied your request. The Plan says the service is not covered.  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.  Diagnosis: R97.20- Elevated prostate specific antigen [PSA]. Screening services without a valid medical diagnosis related to the health of the patient are not a benefit. Medicare recognizes that evidence for clinical utility for: SelectMDx. in males with previous negative prostate biopsy who are being considered for repeat biopsy is promising with evidence of some clinical utility to reduce unnecessary repeat prostate biopsies. There was no documented result of prior prostate biopsy. There was no documented significant interval increase in PSA level. Therefore, we decided that the Plan does not have to pay for the SelectMDX testing (CPT code 81479) provided to the enrollee on September 29, 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 deconditioned from myopathy and although is improving still requires 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on July 6, 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 were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (93042) provided on July 29, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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. In this case, we have confirmed that code 93042 is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (93042) provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit services provided on October 13, 2021, by a provider who has opted out of the Medicare program.  You asked the Plan to pay for the office visit services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider has opted out of the Medicare program.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit services provided on October 13, 2021, by a provider who has opted out of the Medicare program.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer device.  You asked the Plan to pre-approve the Superion procedure. You say that this is a medically necessary procedure to treat the enrollee's condition. The Plan denied your request. The Plan says there is not sufficient evidence to support this surgery for the enrollee.  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 Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Superion device is experimental. More research is needed to show safety and efficacy.      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 Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer device.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services provided to the enrollee on September 4, 2021 and billed under code 70544.  You asked the Plan to pay for physician services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says a National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edit exists between codes 70551 and 70544.  This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed.  However, the modifier was not included on the claim.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code and when required the appropriate modifier. In this case, we have confirmed that this claim has not been billed with an appropriate modifier. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on September 4, 2021 and billed under code 70544.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy rendered on August 9, 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 covered.  The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.  We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on August 9, 2021.  Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.