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

We decided that the Plan does not have to pay for the normal saline solution infusion provided on June 28, 2021.
You asked the Plan to pay for the normal saline solution infusion. You say that this was an emergency service and needed by the patient. You say that the payment allowed was not sufficient to meet the expenses and the best amount possible should be sent. The Plan denied your request. The Plan says procedures should be reported with the most comprehensive CPT code that describes the services performed.
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 J7050 is infusion, normal saline solution, 250 cc.
We asked our coder 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 normal saline solution infusion. Our reviewer says that the documentation submitted was reviewed and it does not meet the criteria for coverage. Our reviewer found that the emergency room report does not include documentation that an infusion of normal saline solution was administered. Our reviewer says that the documentation supports a left ear lavage was performed; therefore, J7050 would not be covered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the normal saline solution infusion have not been met. Therefore, we decided that the Plan does not have to pay for the normal saline solution infusion provided on June 28, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 99358 and 99359
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed and approved for payment based on the medical documentation. The Plan denied your request. The Plan says there are more appropriate codes than what was billed for the services received.
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 99358 is extended patient service without direct patient contact, first hour. The CPT Code Manual definition of code 99359 is extended patient service without direct patient contact, each additional 30 minutes.
We asked our coder 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 medical services. Our reviewer says that the medical documentation does not support the services as billed. Our reviewer found that the services were reported incorrectly. CPT 99358 and CPT 99359 are both for without direct patient contact. Documentation describes prolonged services for face to face and non-face to face contact are being reported with CPT 99358 and CPT 99359. There is a more appropriate coding to report for these services. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 99358 and 99359
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not meet criteria for SNF services. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral exam (D0120) and cleaning (D1110) 
provided on June 15, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that that plan has paid for dental services 
from this dentist in the past. The Plan denied your request. The Plan says the provider in this case has opted out 
of Medicare. The Plan also says that payment cannot be made to dentists that have opted out of Medicare. 
 
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 and the services are listed as covered, 
dental services received from dentists that have opted out of Medicare are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to reimburse you for the oral exam (D0120) and 
cleaning (D1110) provided on June 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 enrollee's current immobility and non-weight bearing status on left, as well as need for multiple intravenous (IV) antibiotics. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the enrollee's records show that they do not require supervision of a rehabilitation doctor at least three (3) times per week and the enrollee does not require aggressive therapies by an intensive team in order to properly regain the enrollee's function. The enrollee can safely receive the services the enrollee needs in other settings, for example: a skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical management of a left foot diabetic food wound. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee 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 this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
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 your wounds will not heal properly, and you will 
lose the strength that you just regained. 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. The Plan states 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that the SNF services are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does 
not require skilled nursing or therapy services on a daily 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 skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from July 14, 2020, through
July 16, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism.
You asked the Plan to pay for inpatient services provided from July 14, 2020, through July 16, 2020 with the
reported principal diagnosis A41.9, sepsis, unspecified organism. The Plan denied your request. The Plan says
although the provider documented sepsis and acute respiratory failure, reasonable support within the
health record must be present for that diagnosis.
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 principal diagnosis A41.9, sepsis, unspecified
organism. 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 services with the reported
principal diagnosis A41.9, sepsis, unspecified organism. Our reviewer says that the documentation does not
support that the inpatient care is payable as billed. Our physician reviewer found that the documentation
supported an admission for Pneumonia, unspecified organism. The documentation was inconsistent regarding a
diagnosis of sepsis and acute respiratory failure. Even though sepsis is documented in the physician query and
discharge summary and acute respiratory failure documented in the discharge summary, supporting medical
record documentation was not found within the record. While the enrollee's presentation warranted
consideration of sepsis as a diagnosis, there was no clinical or laboratory evidence of sepsis. Treatment
consistent with acute respiratory failure including administration of oxygen 5L or greater or provision of
BiPAP and/or mechanical ventilation was not within the documentation. The emergence department and notes
state pulmonary effort is normal. No respiratory distress. The review has determined that the principal
diagnosis A41.9, Sepsis, unspecified organism, was not supported by the medical records.
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 services provided from July 14, 2020, through July 16, 2020 with the reported principal diagnosis
A41.9, sepsis, unspecified organism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group2 heavy-duty power wheelchair (K0825) and accessories to be provided by an out-of-network provider.
You asked the Plan to pre-approve a Group2 heavy-duty power wheelchair and accessories. You say that you were never told by a representative of the Plan that the supplier is out-of-network. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a Group2 heavy-duty power wheelchair (K0825) and accessories to be provided by an out-of-network provider.
Your complaint about receiving erroneous or incomplete information about your network of providers from a representative of the Plan 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 pre-approve routine toenail trimming.
You asked the Plan to pre-approve the toenail trimming. You say that you would like to appeal the denial that you do not qualify for at risk nail care. You were referred to Podiatry by your dermatologist because she recognized that you are at a high risk for infection. The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis for at risk nail care.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. Records do not show that any of these conditions are present. The services you are asking the Plan to pre-approve are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the toenail trimming have not been met. Therefore, we decided that the Plan does not have to pre-approve routine toenail trimming.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on March 15, 2021, billed with two units of code 81404, one unit of 81185, and one unit of 81479.
You asked the Plan to pay for the lab testing as billed. You say that this should be paid. The Plan denied your request. The Plan says the wrong POS code was used on this claim. In spite of this error, the Plan elected to pay some of the billed codes.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the lab testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on March 15, 2021, billed with two units of code 81404, one unit of 81185, and one unit of 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058).
You asked the Plan to pre-approve an endosteal implant, abutment and abutment supported crown. You say that the services should be covered. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefits.
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 pre-approve
surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you would rather go somewhere closer. The Plan denied your request. The Plan says your needs can be met by an in-network provider.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network (OON) provider
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the drug testing (G0483) provided on June 8, 2021.
You asked the Plan to pay for code G0483. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the medical records do not support the billing of code G0483.
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 G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is supported in the medical record. Specifically, the laboratory report shows that more than 22 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of code G0483 have been met. Therefore, we decided that the Plan has to pay for the drug testing (G0483) provided on June 8, 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.