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

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve the SNF admission. You say that please allow skilled nursing services for this enrollee. You are appealing on behalf of the enrollee. The Plan denied your request. The Plan says the Medicare criteria for SNF level of coverage were not 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a double shower head (A9270) provided on October 14, 2020.

You asked the Plan to pay for a double shower head. You say that you needed this equipment before you could return home. The Plan denied your request. The Plan says this is considered a luxury item and is used for a nonmedical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a double shower head (A9270) provided on October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services and supplies provided on June 1, 2021, by an out-of-network provider.

You asked the Plan to pay for surgical services and supplies. You say that the services at issue were a medical necessity for the enrollee. 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 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 surgical services and supplies provided on June 1, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for cerebral perfusion analysis using computed tomography (0042T) provided on May 22, 2021.

You asked the Plan to pay for cerebral perfusion analysis using computed tomography. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that CTP is medically reasonable and necessary when all the conditions listed in the Medicare rules section are fulfilled.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cerebral perfusion analysis using computed tomography have not been met. Specifically, the provided medical records do not support that treatment of the enrollee's condition could have been started within 6-24 hours of the last time the enrollee was known to be at neurologic baseline. Therefore, we decided that the Plan does not have to pay for cerebral perfusion analysis using computed tomography (0042T) provided on May 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 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 enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from continued physical therapy, and occupational therapy, his rehab needs can be safely provided in an alternate and low intensity setting such as in home with aide services and continued therapies.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgical spinal nerve block performed on August 5, 2021.

You asked the Plan to waive the copayment for the outpatient surgery. You say that the services should be covered as your previous surgery being done incorrectly caused your current issues. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 a $275 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $275 copayment for outpatient surgery. The record indicates that these services were performed in an outpatient setting. 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 outpatient surgical spinal nerve block performed on August 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 28, 2021.

You asked the Plan to pay for the SNF services. You say that you feel that the Plan should cover for the SNF services. The Plan denied your request. The Plan says the Medicare criteria for SNF level of coverage were not 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 28, 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 at a lower level of care, such as at a skilled nursing 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 above.
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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services
with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for injection of epoetin alfa and hematology office visits provided on May 28, 2021 and June 25, 2021.

You asked the Plan to waive the cost-sharing for epoetin alfa and specialist visits. You say that you are used to paying only $80 for two combined visits. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.

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 20% coinsurance for epoetin alfa and $40 copayment for each specialist visit. The allowed amounts of the epoetin alfa injections total $705.60, resulting in a coinsurance amount of $141.12. There were 2 specialist visits, resulting in a copayment amount of $80. Your total cost-sharing responsibility is therefore $221.12. 

You have been asked to pay 20% coinsurance for epoetin alfa and $40 copayment for each specialist visit. Epoetin alfa and specialist visits fall within the "Medicare Part B Prescription Drugs" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 cost-sharing for injection of epoetin alfa and hematology office visits provided on May 28, 2021 and June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 23,
2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the denied codes remain not supported.

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 the denied codes are not supported in the medical record. Specifically, the place of service on the
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's
office (POS 11). 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 laboratory services provided to the
enrollee on April 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services (procedure code 57150) provided to the enrollee on May 19, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare does not pay for a service included within another service.

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 57150 is "Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease." 

We find that CPT code 57150 is not supported in the medical record. Specifically, this code is included in the payment for another service, and cannot be reported separately. 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 medical services (procedure code 57150) provided to the enrollee on May 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, chest (71045) radiologic examination, abdomen (74018) provided July 8, 2021.

You asked the Plan to pay for the diagnostic service. You say that the enrollee had multiple exams on this date of service. Attached are reports to support level of service. Please reconsider for processing. The Plan denied your request. The Plan says this claim is already processed.

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 find that CPT code 71045 and 74018 is not supported in the medical record. Specifically, the submitted documentation supports 1 unit each of 71045 and 74018 which have already been previously approved and paid on check dated August 5, 2021. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for radiologic examination, chest (71045) radiologic examination, abdomen (74018) provided July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture and lower partial denture provided on October 14, 2021.

You asked the Plan to pay for the complete upper denture and lower partial denture. You say that you had your mouth repaired and needed dentures. You say that you have never asked insurance to pay for any dental work in the past and you don't have the funds to pay. The Plan denied your request. The Plan says after the maximum benefit allowed is exhausted, any remaining charges are your responsibility.

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, you also have a maximum benefit of $2,500 for covered dental services every year. The Plan paid $2,500 for dental services provided in 2021 prior to receiving these services, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the complete upper denture and lower partial denture provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on May 26, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON dermatology services. You say that your dermatology group cannot join the Plan's network, and you have provided medical records to support payment for these services. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

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.

Records show that both the rendering provider and the referring provider are OON providers 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 dermatology services provided on May 26, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a spinal injection provided on July 26,
2021, at an ambulatory surgical center.
You asked the Plan to waive the copayment for a spinal injection. You say that you have had this procedure
done at this facility in the past and never had any issues. The Plan denied your request. The Plan says the
correct copayment was 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 $300
copayment for each Medicare-covered ambulatory surgical center visit.
You have been asked to pay a $300 copayment for a spinal injection. A spinal injection falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" 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 a spinal injection provided
on July 26, 2021, at an ambulatory surgical center.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for coronary artery bypass grafting. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the ventral hernia repair services provided on May 13, 2021,
billed with code 49561-22-59.

You asked the Plan to pay for the ventral hernia repair as billed. You say that this should be paid as billed. The
Plan denied your request. The Plan says code 49561 is considered to be inclusive to code 47562.

The Plan follows Medicare rules. Medicare rules say that when two codes are in an NCCI edit pair, only the
Column 1 code is payable, unless the Column 2 code is billed with a clinically appropriate modifier.
In this case, code 49561 is a Column 2 code in relation to code 47562. It was billed with modifier -59 which
could bypass the modifier only if clinically appropriate.

We asked our coding 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 ventral hernia repair as billed. Our
reviewer says that the documentation does not support that the services described by code 49561 are separate
and distinct, meaning that the use of modifier -59 is not clinically appropriate. Our coding reviewer found the
operative report does not document a separate incision or separate session, to support hernia repair as a separate
procedure from Laparoscopic cholecystectomy. If a patient undergoes an open cholecystectomy and has a
reducible umbilical hernia repaired during the same operative session through the same incision, these services
cannot be reported separately.

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 ventral hernia repair as billed have not been met. Therefore, we decided that
the Plan does not have to pay for the ventral hernia repair services provided on May 13, 2021, billed with code
49561-22-59.