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

We decided that the Plan does not have to pay for the thyroxine testing represented by code 84439 provided on January 19, 2021.

You asked the Plan to pay for code 84439. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

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 84439 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 84439 have not been met. Therefore, we decided that the Plan does not have to pay for the thyroxine testing represented by code 84439 provided on January 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia 125 mg/mL syringe.

You asked the Plan to pre-approve Orencia. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested drug is not covered under the Plan's medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Orencia 125 mg/mL syringe.

Benefits for Orencia 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: 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 you need assistance walking and to use the bathroom. The Plan denied your request. The Plan says that the records do not support the need for daily therapy on an inpatient basis.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the paravertebral facet joint injection represented by code 64493 provided on January 6, 2021.

You asked the Plan to pay for code 64493. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

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 64493 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 64493 have not been met. Therefore, we decided that the Plan does not have to pay for the paravertebral facet joint injection represented by code 64493 provided on January 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted laparoscopy procedure, abdomen, peritoneum and omentum services coded 49329 provided on April 9, 2021.

You asked the Plan to pay for the unlisted laparoscopy procedure, abdomen, peritoneum and omentum services. 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 supported by the documentation.

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 49329 is unlisted laparoscopy procedure, abdomen, peritoneum and omentum. 

We find that CPT code 49329 is not supported in the medical record. Specifically, the operative report did not include documentation of an unlisted laparoscopic procedure of the abdomen, peritoneum and omentum; therefore, code 49329 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the unlisted laparoscopy procedure, abdomen, peritoneum and omentum services have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted laparoscopy procedure, abdomen, peritoneum and omentum services coded 49329 provided on April 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically appropriate for the enrollee. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.

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 does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our reviewer found that 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 Plan. Our physician reviewer also found that 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve parenteral nutrition (B4185).
You asked the Plan to pre-approve parenteral nutrition. You say that the service is medically necessary. The Plan denied your request. The Plan says you do not have a permanent problem with your digestive tract that keeps you from absorbing the food you eat.
The Plan follows Medicare rules. Medicare rules say that for parenteral nutrition to be considered reasonable and necessary, the treating practitioner must document that enteral nutrition has been considered and ruled out, tried and been found ineffective, or that EN exacerbates gastrointestinal tract dysfunction. The beneficiary must have (a) a condition involving the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients or (b) disease of the stomach and/or intestine which is a motility disorder and impairs
the ability of nutrients to be transported through and absorbed by the gastrointestinal (GI) system. The
beneficiary must have a permanent impairment.
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 parenteral nutrition. Our reviewer says
that the service is not medically necessary. Our physician reviewer found the enrollee does not have a condition
involving the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients
or (b) disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to
be transported through and absorbed by the gastrointestinal (GI) system.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of parenteral nutrition have not been met. Therefore, we decided that the Plan does
not have to pre-approve parenteral nutrition (B4185).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 services performed by a qualified physical therapist (G0151 x9) and 7 direct skilled nursing services of a RN (G0299 x7).

You asked the Plan to pre-approve the services performed by a qualified physical therapist and direct skilled nursing services of a RN. You say that the enrollee would benefit from medically necessary skilled intervention. The Plan denied your request. The Plan says the requested care is for convenience and does not meet criteria.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services performed by a qualified physical therapist and direct skilled nursing services of a RN. Our reviewer says that the requested, ongoing, home health RN and home health physical therapy services are not medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented skilled nursing needs. Our reviewer also found that the enrollee does not have documented skilled therapy needs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services performed by a qualified physical therapist and direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 services performed by a qualified physical therapist (G0151 x9) and 7 direct skilled nursing services of a RN (G0299 x7).
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the emergency transport (A0427) and ground mileage (A0425) provided on December 23, 2020.

You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The Plan denied your request. The Plan says that the emergency transport services were not medically necessary.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. 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 the ambulance services. Our reviewer says that the ambulance services are medically necessary. Our physician reviewer found the record indicates that the ambulance was dispatched due to enrollee having shortness of breath, headache and diarrhea. The reviewer found that a similarly situated prudent layperson would believe that without immediate medical attention there would be serious jeopardy to his or her health. The reviewer found that the elements of the coverage criteria are satisfied. Therefore, the reviewer found that the ambulance services are medically reasonable and 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 the ambulance services have been met. Therefore, we decided that the Plan has to pay for the emergency transport (A0427) and ground mileage (A0425) provided on December 23, 2020.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

We looked at the file, the Plan's contract and Medicare rules. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the patient's medical record must reflect that the service billed was reasonable and necessary. 

When more than two codes from this list are submitted for the same beneficiary on the same date of service, the claims processing system will reject every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service. 

In this case, the medical records provided do not confirm that the labs were billed correctly. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the fine needle aspiration biopsy, including ultrasound guidance (10005) provided on October 14, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $350 for each visit to an outpatient hospital facility. 

You have been asked to pay $350 for the outpatient surgery provided. 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 fine needle aspiration biopsy, including ultrasound guidance (10005) provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit and allergy testing provided on February 23, 2021.
You asked the Plan to pay for the office visit and allergy testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the office visit and allergy testing by a contract provider. The file does not show that the Plan provided notice that the office visit and allergy testing would not be covered. Under Medicare rules, this means the office visit and allergy testing is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the office visit and allergy testing provided on February 23, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies provided on March 31, 2021.
You asked the Plan to pay for incontinence supplies. You say that your medication makes you go to the bathroom frequently. The Plan denied your request. The Plan says the supplies are not covered by Medicare or your plan.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to make additional payment for the first pair of lenses and frames. We decided
that the Plan does not have to make additional payment for the second discounted lenses and frames.
You asked the Plan to make additional payment for the first pair of lenses and frames. You say that you believe
that you should be reimbursed for what you paid for these items. The Plan says that we have concluded that the
member did not have vision coverage with the plan when the first pair of glasses was purchased on August 12,
2020.
We decided that the Plan has to make additional payment for the first pair of lenses and frames.
The Plan follows Medicare rules. Medicare rules say that while Medicare does not cover routine eyewear, the
Plan offers a benefit which covers up to $400 toward one pair of eyeglasses.
In this case, the Plan has not provided a valid denial rationale as it appears to refer to a different date of service.
We have confirmed that you were a member of the Plan on the date of service at issue in this case. This Plan
had a mandatory vision benefit, so this means you did have active vision coverage. It appears that you were
asked to pay $105 at the time of sale for the first pair. The Plan has not provided proof that it paid the
maximum $400 benefit for this one pair. As such, they must ensure you are not responsible for any amounts
charged for the first pair, as this item's cost did not exceed the $400 allowance. Therefore, we decided that the
Plan has to make additional payment for the first pair of lenses and frames.
We also decided that the Plan does not have to make additional payment for the second discounted lenses
and frames.
The Plan follows Medicare rules. As noted above, the benefit for routine eyewear is limited to one pair per
year.
The documentation shows that you purchased a second pair with a discount being applied. This amount is your
responsibility as a second pair is not covered by your benefit. Therefore, we decided that the Plan does not have
to make additional payment for the second discounted lenses and frames.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.

You asked the Plan to pre-approve the IRF care. You say that your surgeon feels a week to 10 days should be sufficient to restore mobility. The Plan denied your request. The Plan says an intensive rehabilitation program 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do 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 a intensive, multi-disciplinary rehabilitation program. Our physician reviewer also found that 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 the acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on April 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that you are unable to determine whether services require prior authorization. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the lab services at issue in this appeal. The Plan did not pre-approve the services 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 the drug testing services provided on April 26, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) provided on April 24, 2021.

You asked the Plan to pay for the CT. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 71250 for the CT has a bundled relationship with code 71275 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 the computed tomography (CT) provided on April 24, 2021.