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

We decided that the Plan does not have to pay for lab services (85610, 82105, 80053, 85025) provided on
January 14, 2021.

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 there were 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 services 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 these services. Therefore, we decided
that the Plan does not have to pay for lab services (85610, 82105, 80053, 85025) provided on January 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 2, 2021, to April 3, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care was clearly medically necessary. The Plan denied your request. The Plan says the inpatient care was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care.
Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. The enrollee was admitted for intravenous antibiotics and pain control. The reviewer also found that the enrollee signed out against medical advice the following day. Therefore, the reviewer found that the inpatient care was not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided April 2, 2021, to April 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on November 13, 2020 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 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 domiciliary visit provided on November 13, 
2020 by an out-of-network (OON) provider.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee is generally not stable enough for 
transfer at this time. Acute care services can be safely administered at the current facility for the time being 
until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current 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 LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for wound debridement provided on April 8, 2021.

You asked the Plan to pay for wound debridement. You say that the enclosed medical records note the wound 
size and what was billed. You say that the claim should be reprocessed for payment. The Plan denied your 
request. The Plan says an appropriate modifier was not billed with this code edit. 
 
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 97598 
has a bundled relationship with code 11042 and cannot be paid as billed. This code cannot be paid as a separate 
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for wound debridement provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planning in the upper right, 
lower left and lower right quadrant. 
 
You asked the Plan to pre-approve periodontal scaling and root planning. You say that this treatment is 
medically necessary. The Plan denied your request. The Plan says your x-rays do not show that you have 
noticeable bone loss or hard substance built up on the root of the tooth.

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 periodontal 
scaling and root planning when the services are medically necessary and reasonable.  
 
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 periodontal scaling and root planning. 
Our reviewer says that the criteria for coverage could not be determined. Our physician reviewer found that the 
radiographs submitted were inadequate and we are unable to determine areas of bone loss or subgingival 
calculus formation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling and root planning have not been met. Therefore, we decided 
that the Plan does not have to pre-approve periodontal scaling and root planning in the upper right, lower left 
and lower right quadrant.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the Freestyle test strips.

You asked the Plan to pre-approve the Freestyle test strips. You say that the item is medically necessary. The Plan denied your request. The Plan says that your doctor indicated that you are not testing your blood glucose level greater than six times per day, and therefore do not require a quantity above our covered limit.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the ordering physician is in the Plan's network and the record does not include any clinical information to determine if the coverage criteria have been met. Additionally, Plan criteria for coverage of additional supplies was requested and not received. It is the burden of the Health Plan to substantiate the denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pre-approve the Freestyle test strips.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) coded 95955, the needle electromyography coded 95885, the neuromuscular junction testing coded 95937, the nerve conduction studies coded 95908, and the short-latency somatosensory evoked potential study coded 95927 provided on November 4, 2020.
You asked the Plan to pay for the electroencephalogram (EEG), the needle electromyography, the neuromuscular junction testing, the nerve conduction studies, and the short-latency somatosensory evoked potential study. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 95955, 95885, 95937, 95908, and 95927 are not supported in the medical record. Specifically, the technical report did not include documentation of an electroencephalogram (EEG) during nonintracranial surgery (carotid surgery); therefore, code 95955 cannot be verified.
The technical report did not include documentation of a limited needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; (listed separately in addition to code for primary procedure); therefore, code 95885 cannot be verified.
The technical report did not include documentation of a neuromuscular junction testing (repetitive stimulation, paired stimuli), per each nerve, by any 1 method; therefore, code 95937 cannot be verified.
The technical report did not include documentation of nerve conduction studies; for 3-4 studies; therefore, code 95908 cannot be verified.
The technical report did not include documentation of a short-latency somatosensory evoked potential study in the trunk or head of stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; therefore, code 95927 cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the electroencephalogram (EEG), the needle electromyography, the neuromuscular junction testing, the nerve conduction studies, and the short-latency somatosensory evoked potential study have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) coded 95955, the needle electromyography coded 95885, the neuromuscular junction testing coded 95937, the nerve conduction studies coded 95908, and the short-latency somatosensory evoked potential study coded 95927 provided on November 4, 2020.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on May 12, 2021.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent. There were 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 services 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 these services. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology consultation services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON cardiology consultation services. You say that your surgeon found an issue on the electrocardiogram and cannot move forward with the surgery for stage 2 breast cancer. You say that the requested cardiology consultation is medically necessary. The Plan denied your request. The Plan says there are in network providers within a reasonable distance from the enrollee who can provide a cardiology consultation within the week.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the cardiology consultation services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services with an out of network provider.
Therefore, we decided that the Plan does not have to pre-approve cardiology consultation services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the microslide consultation services provided on February 4, 2021.

You asked the Plan to pay for the services provided. You say that the services were required to be provided. The Plan denied your request. The Plan says the rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 5 units of this code, exceeding the MUE. 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 microslide consultation services provided on February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 22, 2020.
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 provided on December 22, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care provided from April 26, 2019, to May 1, 2019, and billed
with diagnosis related group (DRG) 100.
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your
request. The Plan says that the records support diagnosis related group 951 rather than 100.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, although the Plan references medical records in their decision, they
did not include any medical records in the case file. Without this information, the Plan's denial cannot be
verified. Therefore, we decided that the Plan has to pay for inpatient care provided from April 26, 2019, to May
1, 2019, and billed with diagnosis related group (DRG) 100.
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 Otezla for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Otezla for the enrollee.

Benefits for this drug 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: 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 medical records provided support the need for care in an LTACH. The Plan denied your request. The Plan says the criteria for coverage have not been met. The Plan says that the enrollee's needs are being met in the current acute setting.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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.