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

We decided that the Plan does not have to pay for a transrectal ultrasound (76873) provided on February 27, 2019.You asked the Plan to pay for the ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of an ultrasound, transrectal; prostate volume study for brachytherapy treatment planning for the billed date of 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 76873 is ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure).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 ultrasound. Our reviewer says that 76873 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation that an Ultrasound, transrectal; prostate volume study for brachytherapy planning (separate procedure) was performed on February 27, 2019.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 ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for a transrectal ultrasound (76873) provided on February 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from August 21, 2019 through August 22, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the care provided on the dates of service were warranted and supported by clinical documentation in the medical record. You further say that the treatment and appropriate care for the enrollee presenting with an alerted mental status could not have been performed in an outpatient setting.The Plan denied your request. The Plan says based on the clinical documentation provided, it was determined that services rendered could have been done safely at the observation level or outpatient/alternate level of care and did not require an acute admission.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from August 21, 2019 through August 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve myocardial imaging (78492).You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan denied your request. The Plan says there is an approval for the same test on file and the record does not show the outcome of this test.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicarerules to determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that the PET Scan is not medically necessary. Our physician reviewer found the member has no documented cardiac symptoms, no ischemia, no LV systolic dysfunction and no ischemic ECG changes.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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial imaging (78492).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283) provided on July 2, 2019.You asked the Plan to pay for the electrical stimulation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of Electrical stimulation (unattended), toone or more areas for indication(s) other than wound care, as part of a therapy plan of care.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 G0283 is electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care.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 electrical stimulation. Our reviewer says that CPT code G0283 is not supported. Our reviewer found the record does not contain evidence that electrical stimulation was performed during this episode of care.
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 electrical stimulation have not been met. Therefore, we decided that the Plan does not have to pay for electrical stimulation (G0283) provided on July 2, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital admission requested on January 10, 2020.You asked the Plan to pay forthe inpatient admission. You say that the enrollee is appropriate for acute inpatient care.The Plan denied your request. The Plan says there is no need for inpatient admission. The enrollee was medically improved after treatment and could be held for observation.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found The enrollee presented to the ED on 1/9/2020 with complaint of cough and shortness of breath. There were crackles in the right lower lobe. She was admitted from bronchitic vs early pneumonia. She received once intravenous fluid, daily intravenous ceftriaxone and oral zithromax. By 1/10/2020, symptoms were much improved. Pulse ox was 93 % on room air. Her intravenous fluids were discontinued and oral antibiotics continued.Based on the submitted documentation, the enrollee was clinically stable at the time of admission and required no supplemental oxygen and showed no signs of sepsis. She wasclinically improve, still did not require supplemental oxygen, still showed no signs of sepsis and was tolerating oral medication after the first midnight's time of care. There was no documentation of any condition for which inpatient care was 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 the inpatient admission have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital admission requested on January 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for monitoring services provided to the enrollee on September 18, 2018 and billed under code 95999.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria are not met.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 asked our coding consultant 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 this service. Our consultant says that Medicare billing criteria are not met. Our consultant foundthat based on the AMA CPT Assistant, February 2016, Volume 26, Issue 2, pages 13, 14:"Train of four"is bundled with the intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials (MEP) and, therefore, is not separately reportable.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay formonitoring services provided to the enrollee on September 18, 2018 and billed under code 95999
Appeal type: Supplemental Benefit
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 requested drug is medically necessary.The Plan denied your request. The Plan says the information submitted doesnot meet the plan's medical necessity guidelines for coverage. The plan says that the enrollee has not tried treatment with zoledronic acid first.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found an XR DXA Bone Density study documents that the enrollee has osteopenia with moderate risk of fracture. Our physician reviewer found that the Plan requires a trial of the drug zoledronic acid before they will approve Prolia. Our physician reviewer found that the enrollee has not tried and failed the required drug. Our physician reviewer found that the enrollee has not tried and failed the required drug. Our physician reviewer found that the documentation does not support that zoledronic acid would be less effective or have adverse effects for the enrollee in this case.We looked at this physician'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neuromuscular stimulator for the enrollee to be provided by out of network provider.You asked the Plan to pre-approve these services. You say that the enrollee would like to try this before any other procedures.The Plan denied your request. The Plan says thata network gap does not exist.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 pre-approved care.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-approvea neuromuscular stimulator for the enrollee to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea Freestyle Libre system.You asked the Planto pre-approvethe system. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee is stable and does not require more than two injections per day.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct indenying the request to pre-approve the system. Our reviewer says that the requested system is not medically reasonable or necessary. Our physician reviewer found a provider note dated 8/23/19 states the enrollee's diabetes has been stable with no hypoglycemic episodes. There was no discussion in this document regarding frequency, challenges or concerns regarding glucose monitoring. The documentation does not discuss how continuous monitoring would change treatment plan. Without the support of the documentation, medical necessity is not determined.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 system have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea Freestyle Libre system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cell examination of body fluids (88104) and fine needle aspiration with biopsy, including ultrasound guidance (10005) provided on August 29, 2019.You asked the Plan to waive the copayment forcell examination of body fluids and fine needle aspiration with biopsy, including ultrasound guidance. You say that the doctor took a needle and 3 specimens from your thyroid gland. You say the doctor did not take enough to determine any results and this was not surgery.The Plan denied your request. The Plan says outpatient surgery services have a $350 copayment.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 $350 copayment for outpatient surgery services. You have been asked to pay a $350 copayment for cell examination of body fluidsand fine needle aspiration with biopsy, including ultrasound guidance. These servicesfall within the outpatient surgery services benefit category. The allowable amount for this service minus the Plan's share equals your cost sharing ($538.36-$188.36 = $350). 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 forcell examination of body fluids (88104) and fine needle aspiration with biopsy, including ultrasound guidance (10005) provided on August 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRabeprazole for the enrollee.You asked the Plan to pre-approveRabeprazole. You say that discontinuation of this medication would be detrimental to health and wellbeing.The Plan denied your request. The Plan says that they do not cover outpatient prescription drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveRabeprazole for the enrollee.Benefits for Rabeprazolemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEnbrel Sure Click Inj 50mg/ml for the enrollee.You asked the Plan to pre-approvethe drug. You say that this is medically necessary.The Plan denied your request. The Plan says this medication does not fall under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveEnbrel Sure Click Inj 50mg/ml for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ritixumab (J9312).You asked the Plan to pre-approve the Ritixumab. You say that the injection is medically necessary. The Plan denied your request. The Plan says the documentation does not support the medical necessity for a step therapy exception.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Ritixumab. Our reviewer says that the provided medical records do not indicate that the patient has tried and failed. Our physician reviewer found the provided medical records do not document clearly that the Plan's required drugs would likely be less effective and/or likely have adverse effects.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 Ritixumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Ritixumab (J9312).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided on September 25, 2018 through September 26, 2018.You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plansays the physician did not expect the member's necessary hospital care would span 2 midnights.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the provided medical records at the time of inpatient admission there is no documentation that the admitting physician reasonably expected that the member's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on September 25, 2018 through September 26, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean exception to the 50 mile limit for routine transportation.You asked the Plan to pre-approveexceptions to supplemental benefits. You say that you need to see your doctor for a pre-surgery visit.The Plan denied your request. The Plan says that your request exceeds the benefit limit.Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits.Therefore, we decided that the Plan does not have to pre-approvean exception to the 50 mile limit for routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the clinical information provided supports the need for IRF care.The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of IRF care. The plan says that the enrollee could receive care in another setting.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Our physician reviewer found that ongoing pain medication and other medication management, skin and oxygen care, and daily therapy can be provided at a SNF. Our physician reviewer found that the enrollee is mostly minimal assist for function transfers and activities of daily living. Our physician reviewer found that a less intensive, longer duration of therapy will allow for measurable and predictable gains to be attained within a predicted time period. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.