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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received in another setting.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that you require skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis may be appropriate in this case if a therapy re-evaluation sees potential for any further improvement in your function. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression wraps (A6549).

You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are non-covered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve gradient compression wraps (A6549).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 29,
2021.

You asked the Plan to pay for these services. . You say that these services should be covered by the Plan. 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 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 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 physician services provided to the enrollee on
April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a genetic cancer screening (81479) provided on January 26, 2021.

You asked the Plan to pay for a genetic cancer screening. You say that this was medically necessary. The Plan denied your request. The Plan says this was a screening service.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a genetic cancer screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a genetic cancer screening (81479) provided on January 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (93926-LT, 93926-RT, 93971-RT) provided from January 7, 2021, to January 14, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. Medicare rules also say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and Medicare rules. The services (93926-LT) provided on January 7, 2021, were billed on a duplicate claim to one previously processed and paid by the Plan. Duplicate claims are not payable. We also find that CPT codes 93926-RT and 93971-RT are not supported in the medical record. Specifically, the services were billed with diagnosis code I70.262 (Artherosclerosis of native arteries of extremities with gangrene, left leg). It is inappropriate to bill the -RT modifier for a left-sided diagnosis 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 services (93926-LT, 93926-RT, 93971-RT) provided from January 7, 2021, to January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $45 copayments for specialists' services provided on April
14, 2021 and May 14, 2021.
You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct.
The Plan denied your request. The Plan says these copayments were applied based on the services billed by
your provider and the Plan contract agreement.
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 $45
copayment for each specialist visit. You have been asked to pay the correct amount based on the contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore,
we decided that the Plan does not have to waive the $45 copayments for specialists' services provided on April
14, 2021 and May 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.

The plan has approved Prolia under the enrollee's Medicare Part D coverage. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the diagnostic cats (D0470) provided on March 30, 2021, and an
occlusal guard adjustment (D9943) provided on May 27, 2021.
You asked the Plan to pay for the diagnostic casts and guard adjustment. You say that these services were
medically necessary to treat your TMJ syndrome, which makes your day-to-day life difficult. The Plan denied
your request. The Plan says that they have agreed to cover the occlusal guard (D9940), as their physician
reviewer found this service is medically necessary. However, the diagnostic casts and guard adjustment are not
covered services.
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, no medical records were provided with this request. Treatment of
TMJ can be covered when medically necessary, but without medical records, the denial is not substantiated.
Therefore, we decided that the Plan has to pay for the diagnostic cats (D0470) provided on March 30, 2021,
and an occlusal guard adjustment (D9943) provided on May 27, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the WATS 3D brush biopsy rendered on February 16, 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 were not medically necessary.
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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has gastroesophageal reflux disease (GERD) with esophagitis without bleeding and a diaphragmatic hernia without obstruction or gangrene. The American Society of Gastrointestinal Endoscopy suggests using WATS-3D (brush) biopsy testing in patients with known or suspected Barrett's esophagus. The available clinical documentation in the case file does not support that the enrollee in this case has known or suspected Barrett's esophagus. The services were therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the WATS 3D brush biopsy rendered on February 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on June 2, 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 separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on June 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the conductive garment (E0731) provided on April 5, 2021.

You asked the Plan to pay for the conductive garment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records must be amended prior to the medical review.

The Plan must follow Medicare rules. Medicare rules say that when correcting a paper medical record, these principles are generally accomplished by the author of the alteration must sign and date the revision. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the conductive garment have not been met. Specifically, the author of the medical record alteration has not signed and dated the amendments. Therefore, we decided that the Plan does not have to pay for the conductive garment (E0731) provided on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression devices (E0651, E0667) provided on April 16, 2021. You asked the Plan to pay for intermittent limb compression devices. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. 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 intermittent limb compression devices. Our reviewer says that the requested items are not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee did not have a diagnosis of lymphedema. The enrollee did not have all of the following: edema in the affected lower extremity with one or more venous stasis ulcers that have failed to heal after a six-month trial of conservative therapy directed by the treating practitioner. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression devices have not been met. Therefore, we decided that the Plan does not have to pay for intermittent limb compression devices (E0651, E0667) provided on April 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on April 21, 2021.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the review indicates that the submitted documentation did not indicate that the enrollee was medically unstable and required ambulance transport from the hospital to the skilled nursing home.

The review has determined that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation did not support that the ambulance transport on was medically reasonable and necessary for the enrollee 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on April 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided on January 1, 2021, to January 15, 2021.

You asked the Plan to pay for inpatient hospital care. You say that you are appealing the recoupment request. The Plan denied your request. The Plan says the hospital records do not support a diagnosis of sepsis for this hospital admission.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with 856, sepsis, unspecified. 

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 inpatient hospital care. Our reviewer says that the medical records did not support the billing of multiple secondary diagnosis codes and the principal procedure code. Our physician reviewer found that despite presentation with a left neck abscess, there was insufficient evidence for sepsis in this case. The enrollee did not exhibit persistent hypotension or ongoing hemodynamic instability. The enrollee was oxygenating normally. Platelet count, serum creatinine and total bilirubin levels were within normal range. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on January 1, 2021, to January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided December 7, 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 all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 

We looked at the file and Medicare rules. The documentation did not include a physician order for the services at issue. 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 (81479) provided December 7, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy service provided by a certified occupational therapy assistant (COTA) on December 17, 2019.

You asked the Plan to pay for occupational therapy service. You say that the Plan is required to pay a non-contract provider at the preferred provider rate if services are not available from preferred providers in the service area. The Plan denied your request. The Plan says the denial of payment for this service is correct, because a more appropriate procedure code should have been used.

The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's service, because they do not meet the qualifications of a therapist.

We looked at the file and Medicare rules. The record shows that this service was performed by a COTA but has been billed under a Nurse Practitioner (NP). Based on this information, we decided that Medicare rules for coverage of occupational therapy service have not been met. Therefore, we decided that the Plan does not have to pay for occupational therapy service provided by a certified occupational therapy assistant (COTA) on December 17, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for SNF care was not met in this case.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. Therapy four times per week is recommended in the provided records. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).