Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopy services coded 44180 provided on April 6, 2021.
You asked the Plan to pay for the laparoscopy 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 separately 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. In this case, we have confirmed that code 44180 for the laparoscopy services is a column II code to column I code 57425. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopy services coded 44180 provided on April 6, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (CPT code 90832) provided to the enrollee on August 5, 2021, and August 26, 2021, by an out-of-network provider.

You asked the Plan to pay for the out-of-network psychotherapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 requested 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 the psychotherapy services (CPT code 90832) provided to the enrollee on August 5, 2021, and August 26, 2021, by an out-of-network provider.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pulmonary embolism. Medical problems are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
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 stay is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH.

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 indicating medical necessity for 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 they are 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a total electric hospital bed.
You asked the Plan to pay for a total electric hospital bed. You say that you need this item. The Plan denied your request. The Plan says Your request for reimbursement of a bed you bought from a general retailer is not medically necessary under the Medicare guidelines as it is no considered a medical device, it is primarily used for a non-medical purpose and has features that are considered items of convenience.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pay for a total electric hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on May 29, 2021, to June 5, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this stay was because you had Covid-19. You say that you should not be responsible for this. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $395 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care. 

You have been asked to pay a $395 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,975 ($395 x 5 days = $1,975). The correct copayment has been applied to the inpatient hospital care that was provided. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided by a participating provider on May 29, 2021, to June 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you need skilled nursing as you cannot be released home as of now, due to your massive stroke and your inability to function without assistance. The Plan denied your request. The Plan says your request does not meet Medicare guidelines because you are receiving adequate and necessary intensive rehabilitation in the inpatient rehabilitation facility (IRF). The Plan states all the services you need are offered at the IRF and transfer to a SNF for inpatient skilled rehabilitation services is not medically necessary.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (CPT code 93010-77) provided to the enrollee on March 31, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. CPT code 93010-77 denied because it is bundled to another service billed on the same day by the same provider. Per CMS NCCI Procedure-to-Procedure code pair edits, code 93010 is a column II to column I code 33967 (Insertion of intra-aortic balloon assist device, percutaneous).
This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (CPT code 93010-77) provided to the enrollee on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) and an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) provided on May 3, 2021, to May 6, 2021.
You asked the Plan to pay for an intraoral complete series of radiographic images and an adjunctive pre-diagnostic test. You say that you are requesting reconsideration for the denied services. You also say when you arrived at the provider's office, you were asked to pay $50.00 up front, and you are requesting a refund. You say you received a cleaning. You say the provider was rude and cruel to you and you will not return for future care. The Plan denied your request. The Plan says there is no coverage for the services requested.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) and an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) provided on May 3, 2021, to May 6, 2021.
Your complaint about a refund of the money you paid upfront and the provider being rude and cruel to you, is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (99601) provided on April 30, 2021.

You asked the Plan to pay for home infusion therapy. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with a valid code.

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 code 99601 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.

Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601) provided on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital services provided on April 9, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate 
payment is made.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

In this case, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. We find that CPT code 99053 is a bundled code. When 
these services are covered, payment for them is subsumed by the payment for the services to which they are 
incident. Based on this information, we decided that Medicare rules for coverage of the services provided have 
not been met. Therefore, we decided that the Plan does not have to pay for the hospital services provided on 
April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services provided on 
September 9, 2021, by an in-network provider.

You asked the Plan to waive the copayment for the services. You say that you should not have to pay this 
copayment as you were never informed there would be one. You state that you were not told by the provider 
that if there was anything removed or biopsied that it would have a surgical cost. The Plan denied your request. 
The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). 

Review of the file shows that a polyp was removed during the colonoscopy on September 9, 2021, by an innetwork provider. Therefore, the colonoscopy is not routine. The Medicare-allowed amount for the 
colonoscopy is less than the set $250 copayment; therefore, you have been asked to pay the lesser amount of 
$242.30 for the surgical services. Your 2021 EOC states if the screening test results in a biopsy or removal of a 
lesion or growth, the procedure is considered diagnostic and outpatient surgery cost sharing may apply and 
enrollees must pay a $250 copayment per visit, per provider, per day for surgery performed in an in-network 
ambulatory surgical center. 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 outpatient surgical 
services provided on September 9, 2021, by an in-network provider.
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 are requesting acute rehabilitation after a broken
bone from a car crash. The Plan denied your request. The Plan says the stay is not medically necessary based
on IRF criteria.
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. You were admitted for
pelvic fractures and hematoma after an all-terrain vehicle (ATV) accident. Medical problems are stable.
There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for
an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure, atrial fibrillation and gout of the right wrist. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 01844 provided on June 10, 
2021.

You asked the Plan to pay for the anesthesia 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 separately 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.

In this case, the CPT Code Manual definition of code 01844 is anesthesia for vascular shunt, or shunt revision, 
any type (eg, dialysis).

We find that CPT code 01844 is not supported in the medical record. Specifically, this anesthesia service is 
inconsistent with the surgical procedure reported by the surgeon. The surgical procedure reported must align 
with the anesthesia services reported for reimbursement eligibility. Based on this information, we decided that 
Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services coded 01844 provided on June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CGM system (CPT code K0554), for the enrollee.
You asked the Plan to pre-approve the CGM. You say that this should be covered because the enrollee has
mental illness, anxiety and bipolar which results in the enrollee being afraid of needles and you have a hard
time checking the enrollee. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. Based on the information we received, the enrollee does not qualify
for a therapeutic CGM because they do not take insulin every day and they do not adjust their insulin dose
based on the enrollee's blood glucose (BG) results. Based on this information, we decided that Medicare rules
for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve
a CGM system (CPT code K0554), for the enrollee.