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

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.  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 is stable and does not meet Centers for Medicare & Medicaid Services (CMS) coverage criteria for an IRF admission. With the enrollee's current medical stability, and no other acute medical complexity, there is no need for Physical Medicine and Rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs noted in the record. At the current functional level as above, the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. IRF admission is not medically necessary based on lack of medical complexity and nursing needs. The enrollee's rehabilitation can be accomplished with therapies in an alternate setting. Document does not support the necessity for admission to IRF. While the enrollee may benefit from continued physical therapy (PT), and occupational therapy (OT), the enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility (SNF) or in home with therapies.  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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound services (76872) provided on June 12, 2020.  You asked the Plan to pay for the ultrasound services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the procedure is inconsistent with the modifier used.  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 76872 is ultrasound, transrectal.  We find that CPT code 76872 is not supported in the medical record. Specifically, this is a diagnostic procedure that requires a professional component modifier. This modifier was not shown in the file. Based on this information, we decided that Medicare rules for coverage of the ultrasound services have not been met.    Therefore, we decided that the Plan does not have to pay for the ultrasound services (76872) provided on June 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on September 11, 2020.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically reasonable and necessary. Our physician reviewer found that the enrollee was treated at the hospital for Coronavirus (COVID-19) infection and was transported home via ambulance. He was able to ambulate without assistance to cot and transported without need for treatment. The enrollee's vitals were stable. The documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for this enrollee on September 11, 2020.  The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on September 11, 2020. The documentation does not support that the ambulance transport on September 11, 2020 was 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 ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on September 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the imaging services coded as 93976 and 93976 billed with the -59 modifier provided on August 24, 2021.  You asked the Plan to pay for the imaging services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these services have denied correctly based on Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    In this case, we have confirmed that 93976 is a column II code to column I code 76856. 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. However, 93976 billed with the -59 modifier was billed with an appropriate modifier to bypass the e  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 93976 billed with the -59 modifier. Our reviewer says that the documentation does not support this code as billed. Our reviewer found that CPT 76856 includes real-time monitoring, which can show the structure and movement of the body's internal organs. The images can also show blood flowing through blood vessels.  Procedure report does not support CPT 93956 as a distinct procedural service from CPT 76856 as noted above. Modifier 59 should be reported to indicate that a procedure or service was distinct or independent for other service performed on the day which the documentation does not support in this case.  Therefore, we decided that the Plan does not have to pay for the imaging services coded as 93976 and 93976 billed with the -59 modifier provided on August 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on June 14, 2021 by a non-network provider.  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 rendered by a non-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 requested provider in this case is not a network provider with the Plan. The referring provider 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 the laboratory services provided on June 14, 2021 by a non-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for prolotherapy, a TENS device, and intermittent limb compression devices provided on July 21, 2021.  You asked the Plan to pay for prolotherapy, a TENS device, and intermittent limb compression devices. You say that the items/services at issue are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan follows Medicare rules. The rules say that prolotherapy is not a covered benefit. The rules say that the use of TENS for the relief of acute post-operative pain is covered. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.  The file does not show that the enrollee Is using TENS for the relief of acute post-operative pain or that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Prolotherapy is not covered. Therefore, we decided that the Plan does not have to pay for prolotherapy, a TENS device, and intermittent limb compression devices provided on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on August 5, 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 a skilled nursing facility setting and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for Transcutaneous electrical nerve stimulation (TENS) device (E0730), provided on August 8, 2018.  You asked the Plan to waive the copayment for a TENS device. You say that the item should be covered. The Plan denied your request. The Plan says the cost share was applied 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 17% coinsurance for durable medical equipment (DME) and related supplies.    You have been asked to pay a 17% coinsurance for a TENS device. This item falls within the durable medical equipment (DME) and related 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 Transcutaneous electrical nerve stimulation (TENS) device (E0730), provided on August 8, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134) provided on September 13, 2021.  You asked the Plan to waive the copayment for scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral, retina. The Plan denied your request. The Plan says the claim was processed with the correct copayment.  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, Medicare-covered services.    You have been asked to pay a $40 copayment for scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral, retina. The scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral, retina falls within the Vision Care, Medicare-covered 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 scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134) provided on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Coronavirus test rendered on August 20, 2021.  You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied your request. The Plan says the services were for travel purposes and therefore not covered.  The Plan must follow Medicare rules. The rules say that Medicare covers specific preventive services only. The Plan contract says that Coronavirus testing required as a condition of travel inside or outside of the United States and its territories is not covered. The rules say that Medicare generally does not cover items and services furnished outside of the United States.  We looked at the file and Medicare rules. The services at issue are a Coronavirus test for travel purposes. This is a preventive service that is not covered by Medicare or the Plan. Furthermore, the file shows that the services were performed outside of the United States. Therefore, we decided that the Plan does not have to pay for the Coronavirus test rendered on August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for diagnostic mammography, including CAD when performed (77065) diagnostic digital breast tomosynthesis (G0279) provided September 10, 2021.  You asked the Plan to waive the copayment for the diagnostic service. You say that that you had a screening mammogram, but it had to be redone because the images were not clear. The copay should not be your responsibility. The Plan denied your request. The Plan says this claim was processed with the correct copayments applied per the Evidence of Coverage.  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 $100 copayment for each covered x-ray in an outpatient hospital or facility.    You have been asked to pay $106.79 ($83.53 + $23.26) for the diagnostic service. The diagnostic service 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 diagnostic mammography, including CAD when performed (77065) diagnostic digital breast tomosynthesis (G0279) provided September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network services provided on July 22, 2021.  You asked the Plan to pay for these services. You say that these services should be covered by the Plan. You say that you had severe ear pain and needed to go to the doctor. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network services provided on July 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the hand x-ray rendered on September 28, 2021.  You asked the Plan to waive the copayment for these services. You say that you never had an x-ray. The Plan denied your request. The Plan says the copayment was applied 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 $60 copayment for Medicare-covered x-ray and ultrasounds.   Review of the file shows that you received an x-ray of your hand with three views on September 28, 2021. You have been asked to pay a $60 copayment for these services. These services fall within the Medicare-covered x-ray and ultrasounds 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 hand x-ray rendered on September 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that you prefer to admit to acute rehabilitation because you were independent before your hospitalization and you want to return to being independent. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states skilled therapies at home or at a skilled nursing facility may be approved upon request.  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 you are stable with no acute medical illness and does not meet Centers for Medicare & Medicaid Services (CMS) coverage criteria for an IRF admission. With your current medical stability, and no other acute medical complexity, there is no need for Physical Medicine and Rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs noted in the record. At the current functional level as above, you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. IRF admission is not medically necessary based on lack of medical complexity and nursing needs. Document does not support the necessity for admission to IRF. While you may benefit from continued physical therapy (PT), and occupational therapy (OT), your rehabilitation needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility (SNF).  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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Genesight Psychotropic pharmacogenomics panel provided on August 19, 2021.  You asked the Plan to pay for the Genesight panel. You say that this is a covered test and must be paid according to the presiding Medicare contractor's rate. The Plan denied your request. The Plan says this is not considered a medically necessary test.  The Plan must follow Medicare rules. Medicare rules say that review of current literature does not clearly demonstrate that PGx testing panels, such as GeneSight, offers a benefit over selection of medications based on contemporary evidence-based medication selection protocols. Therefore, we decided that the Plan does not have to pay for the Genesight Psychotropic pharmacogenomics panel provided on August 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy services coded as 97110, 97112, and 97116 provided from March 1, 2021, through March 12, 2021.  You asked the Plan to pay for the physical therapy services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says there are more appropriate codes to describe the services than those that have been 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.  In this case, the CPT Code Manual definition of the submitted codes are as follows:  97110 - Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.   97112 - Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.  97116 -  Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing).  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 physical therapy services. Our reviewer says that the services as billed are not supported by the submitted documentation. Our reviewer found that the available documentation supports that a physical therapist visit was performed in the home setting. Services should always be coded to the highest specificity. In this case, as services were performed in the home, there is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code that should be reported for the billed codes in question.   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 physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services coded as 97110, 97112, and 97116 provided from March 1, 2021, through March 12, 2021.