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

We decided that the Plan does not have to pay for BLS non-emergency ambulance service (A0428) and ground mileage (A0425).

You asked the Plan to pay for the ambulance service. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says a physician's office, clinic, outpatient center is not a covered destination.

The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination.

The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for BLS non-emergency ambulance service (A0428) and ground mileage (A0425).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit, for date of service July 14, 2020, at a high complexity level.

You asked the Plan to pay for a high complexity level emergency department visit. You say that the Plan should pay this claim at the high complexity level. The Plan denied your request. The Plan says the records do not support a high complexity level of service therefore the claim was down coded to 99284.

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 99285 is Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. 

We find that CPT code 99285 is not supported in the medical record. Specifically, the record shows no apparent distress, blood work normal, EKG normal. There doesn't appear that there was an immediate significant threat to life or physiologic function. Based on this information, we decided that Medicare rules for coverage of a high severity emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit, for date of service July 14, 2020, at a high complexity level.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (01992, 64493, 64494).

You asked the Plan to pre-approve the facet joint injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that repeat facet joint injections are covered when the first injection results in significant pain relief (more than 50%) for at least 3 months.

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 facet joint injections. Our reviewer says that the facet joint injections are not medically necessary. Our physician reviewer found the record shows the previous injection only resulted in 50% pain relief for a month. Repeat injections are not reasonable. Additionally, insufficient medical rationale for the requirement of sedation is provided.

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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (01992, 64493, 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 8, 2020.

You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $30 copayment for each specialist visit. 

You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on July 8, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee could be treated at 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 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 or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage 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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day and use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that this orthosis was medically necessary. The Plan denied your request. The Plan says there is no evidence in record that the prescribing physician ever saw the member.

The Plan follows Medicare rules. Medicare rules say that the spinal orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically reasonable and necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation and a credible physical examination of the back.

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on October 28, 2020.

You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration because the member had multiple services rendered by providers with different specialties. The Plan denied your request. The Plan says CPT code 99232 was billed by a physician with the same specialty on the same date of service as CPT code 99233.

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 99232 is not supported in the record. Specifically, the record indicates that CPT 99233 was billed and paid to a provider with the same specialty on the same date of service. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99232) provided on October 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) and suspension sleeve (L2397).

You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that these items should be covered.

The Plan denied your request. The Plan says the enrollee did not receive a video or telephonic visit with the ordering physician.

The Plan follows Medicare rules. Medicare rules say that knee orthotics will be denied if only pain or a subjective description of joint instability is documented. Additions will be denied as not reasonable and necessary if the base orthosis is not reasonable and necessary or the addition is not reasonable and necessary.

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 a knee orthosis and suspension sleeve. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not reveal that there was a true objective physical examination indicating evidence of instability with objective joint laxity.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) and suspension sleeve (L2397).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapy provider.

You asked the Plan to pre-approve these services. You say that you do not want to see the network provider. The Plan denied your request. The Plan says the services are available from network providers.

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. The Plan confirmed they have a provider that you have not already seen. 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 referral to an out-of-network physical therapy provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services of home health aide in home health each 15 minutes (G0156).

You asked the Plan to pre-approve the home health aide services. You say that you were already provided with 2 hours a week for home health aide services but you require requires 10 hours a week. The Plan denied your request. The Plan says the request for home health services coded as S9122 is not covered by the plan.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the home health aid services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation doesn't support that the member requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The member does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Furthermore, it is not evident that the member is homebound.

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 home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve services of home health aide in home health each 15 minutes (G0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compression device (E0652) and segmental pneumatic appliance (E0667) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the pneumatic compression device and appliance. You say that please provide GAP authorization. There is no other supplier in the geographical area that can provide the prescribed equipment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan has approved the equipment to be provided from 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 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 pneumatic compression device (E0652) and segmental pneumatic appliance (E0667) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hip arthroscopy.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has left hip pain rated at nine out of 10. Exam of the left hip reveals tenderness over the trochanteric bursa. His range of motion is normal. He had positive FABERS and Obers testing and leg raising bilaterally. A computed tomography (CT) scan is noted to show joint space narrowing and evidence of degenerative joint disease with subchondral cystic change along the superior acetabular roof; no identifiable labral disruption is seen. The use of hip arthroscopy for the enrollee's pathology is not shown to be effective and/or safe. The services are not 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 pre-approve a hip arthroscopy.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacy services, laboratory services, CT scans, physical therapy evaluation, EKG/ECG, and ER services.

You asked the Plan to pay for the pharmacy services, laboratory services, CT scans, physical therapy evaluation, EKG/ECG, and ER services. You say that the enrollee was discharged from hospice prior to this claim's admission date, and then reinstated after the discharge date. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the pharmacy services, laboratory services, CT scans, physical therapy evaluation, EKG/ECG, and ER services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda 25 mg/mL intravenous solution (J9271).

You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that chemotherapy agents are covered when utilized per the NCCN Recommended Use.

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 Keytruda. Our reviewer says that Keytruda is not medically necessary based on the records provided. Our physician reviewer found approval per the NCCN compendia requires the cancer to be PD-L1 positive. The records provided do not show if the cancer has tested positive for this protein.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda 25 mg/mL intravenous solution (J9271).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0482) provided on July 22, 2020.
You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0482) provided on July 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are 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. 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 based on the medical records provided daily
skilled services are not required. The enrollee does 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.