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 the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 based on the medical records provided the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care. 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 venipuncture (36410) and ultrasound guidance (76937)
provided on April 16, 2021.
You asked the Plan to pay for venipuncture and ultrasound guidance. You say that this should not be
considered bundled. The Plan denied your request. The Plan says this cannot be paid 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. In this case, we have confirmed that code 36410
has a bundled relationship with code 71275 and cannot be paid as billed. This code cannot be paid as a separate
line item. Code 76937 is an add-on code that cannot be paid while the primary procedure is denied. Based on
the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not
have to pay for venipuncture (36410) and ultrasound guidance (76937) provided on April 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you appear to have reached potential with your recent SNF stay.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
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 receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF level of care. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided from
May 28, 2021, to June 1, 2021.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that 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 $390
copayment for outpatient surgery, including services provided at hospital outpatient facilities.
You have been asked to pay a $390 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers 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 colonoscopy provided from May
28, 2021, to June 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

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 device. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says alternate settings can be requested.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for thoraco-lumbar-sacral spinal surgery and was discharged home on 10/22/21. Medical
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87338, 82656, 83631, 83520, & 82274) provided June 30, 2020.
You asked the Plan to pay for the lab services. 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 providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 87338, 82656, 83631, 83520, & 82274 are not supported in the medical record. Specifically, the place of service on the claim (81, lab) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87338, 82656, 83631, 83520, & 82274) provided June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine rendered on March 18, 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.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine rendered on March 18, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an injection into a tendon sheath and arthrocentesis provided on June 24, 2021, and June 29, 2021.

You asked the Plan to waive the copayments for an injection into a tendon sheath and arthrocentesis. You say that you have never been charged in the past for injections. 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 $30 copayment for specialist services. 

You received an injection into a tendon sheath on June 24, 2021. This is considered a specialist service. Therefore, you are responsible to pay the $30 copayment.

You received an injection into a tendon sheath on June 29, 2021. This is considered a specialist service. Therefore, you are responsible to pay the $30 copayment. 

The total amount you owe is: $60. 

You have been asked to pay the total copayment amount of $60 for an injection into a tendon sheath and arthrocentesis. An injection into a tendon sheath and arthrocentesis fall within the physician/practitioner services, including doctor's office visits 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 an injection into a tendon sheath and arthrocentesis provided on June 24, 2021, and June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3010).
You asked the Plan to pre-approve foot orthotics. You say that the shoe inserts should be covered. The Plan denied your request. The Plan says this item is not a covered benefit as you do not have documented diabetic foot disease.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3010).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physiologic monitoring treatment management services
(99457 and 99458) provided on May 1, 2021.
You asked the Plan to pay for physiologic monitoring treatment management services. You say that these codes
are payable. The Plan denied your request. The Plan says these codes are not covered on outpatient hospital
bills.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. An Outpatient Prospective Payment System
(OPPS) payment status indicator is assigned to every Healthcare Common Procedure Coding System (HCPCS)
code. The status indicator identifies whether the service described by the HCPCS code is paid under the OPPS
and if so, whether payment is made separately or packaged.
We find that CPT codes 99457 and 99458 are not supported in the medical record. Specifically, these codes
have an OPPS status indicator of B, meaning they are not recognized by OPPS when submitted on an
outpatient hospital Part B bill type. Based on this information, we decided that Medicare rules for coverage of
physiologic monitoring treatment management services have not been met. Therefore, we decided that the Plan
does not have to pay for physiologic monitoring treatment management services (99457 and 99458) provided
on May 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair lift (E1399).

You asked the Plan to pre-approve the wheelchair lift. You say that you require the wheelchair lift to be able to go to the store. The Plan denied your request. The Plan says a wheelchair lift is not a covered item.

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 wheelchair lift (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 9, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee 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 physician services provided to the enrollee on June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for gadobenate dimeglumine injection (MultiHance), per ml (A9577) and magnetic resonance imaging, abdomen (74183) provided June 22, 2021.
You asked the Plan to pay for the diagnostic services. You say that your doctor sent you to have an MRI due to a mass in your pancreas. The Plan denied your request. The Plan says the claim cannot be reprocessed for payment until an explanation of benefits is received from the primary insurance carrier.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan is the secondary insurer. As the secondary insurer, the Plan cannot be held responsible for the diagnostic services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for gadobenate dimeglumine injection (MultiHance), per ml (A9577) and magnetic resonance imaging, abdomen (74183) provided June 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services (procedure code 99380) provided to the enrollee on March 29, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment for this service is always bundled into payment for other services.

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 99380 is "Supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more." 

We find that CPT code 99380 is not supported in the medical record. Specifically, this code cannot be paid for separately, as it has a status indicator of "B", which means payment for this code is always bundled into payment for other service. 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 skilled nursing facility services (procedure code 99380) provided to the enrollee on March 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas device treatments with nutria-pharmaceutical injections provided on March 4, 2021, billed with codes 97112-GP, 97016-76-XS-GP, six units of 96372, and multiple drug codes including J7999, J3490, J3420, J3415, and J1955.

You asked the Plan to pay for the Sanexas device treatments with nutria-pharmaceutical injections as billed. You say that this is correctly billed and represents medically necessary treatment. The Plan denied your request. The Plan says the Medicare rules do not allow coverage of these services for the enrollee's conditions.

The Plan must follow Medicare rules. Medicare rules say that NPPs can only bill for physical therapy services when they are allowed to provide physical therapy by State law. In addition, compounded drugs must be billed with one unit of J7999, with the narrative detailing which drugs are included in which quantities. 

Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NPP. There is no evidence this NPP is licensed to provide physical therapy in Arizona. In addition, the claim lists all drugs in the compounded pre-filled syringe with individual codes which is not supported by Medicare billing rules. Therefore, we decided that the Plan does not have to pay for the Sanexas device treatments with nutria-pharmaceutical injections provided on March 4, 2021, billed with codes 97112-GP, 97016-76-XS-GP, six units of 96372, and multiple drug codes including J7999, J3490, J3420, J3415, and J1955.