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

We decided that the Plan does not have to waive the cost share for the chemodenervation of muscle(s);
muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (64615) and the
Onabotulinumtoxina injections (J0585) provided on October 21, 2020.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to 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 $45
copayment for each specialist in-person office visit. Additionally, you must pay 20% of the cost for Part B
covered chemotherapy drugs and other Part B covered drugs.
You have been asked to pay $283.40 which includes a $45 copayment for the specialist visit and the
Plan allowed amount of $1,192 x 20% coinsurance=$238.40 for the Part B covered drugs provided. 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 share for the chemodenervation of muscle(s); muscle(s) innervated by
facial, trigeminal, cervical spinal and accessory nerves, bilateral (64615) and the Onabotulinumtoxina
injections (J0585) provided on October 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care evaluation and management (99222) provided on January 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the inpatient services. You say that your on call orthopedic physician provided care in good faith and should be reimbursed for these services. You should not be penalized for what the facility did or did not do. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 initial hospital care evaluation and management (99222) provided on January 3, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from June 21, 2018, through
June 25, 2018 with the reported secondary diagnosis K62.5, Hemorrhage of anus and rectum.
You asked the Plan to pay for inpatient services provided from June 21, 2018, through June 25, 2018 with the reported secondary diagnosis K62.5, Hemorrhage of anus and rectum. The Plan denied your request. The Plan says while rectal bleeding was noted on presentation, this is a symptom routinely associated with intussusception and an integral part of the disease process. Therefore, per coding guidelines, K62.5 should not be reported additionally.
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 the reported secondary diagnosis K62.5, Hemorrhage of anus and rectum. 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 provided from June 21, 2018, through June 25, 2018 with the reported secondary diagnosis K62.5, Hemorrhage of anus and rectum. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the enrollee presented to the facility for treatment of diarrhea with bright red blood. In this case, the enrollee presented with abdominal pain and diarrhea with bright red blood. A computed tomography scan of the abdomen was obtained which showed ileocolic intussusception. The enrollee was subsequently taken to the operating room and underwent exploratory laparotomy and right hemicolectomy. While rectal bleeding was noted on presentation, this is a symptom routinely associated with intussusception and an integral part of the disease process. The review has determined that the secondary diagnosis K62.5, Hemorrhage of anus and rectum, 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 June 21, 2018, through June 25, 2018 with the reported secondary diagnosis K62.5, Hemorrhage of anus and rectum.
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 necessary care can be rendered in a lower setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is an off-label and unsupported use of Euflexxa.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular 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 Euflexxa. Our reviewer says that the requested drug is not medically necessary in this case. Our physician reviewer found that the requested use of Euflexxa is not FDA-approved for the enrollee's diagnosis. Its use as prescribed in this case is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for eye muscle revisions (67314) provided on October 14, 2020.
You asked the Plan to pay for eye muscle revisions. You say that this had to be billed with two units. The Plan denied your request. The Plan says this exceeds the MUE for this code.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 67314 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of eye muscle revisions have not been met. Therefore, we decided that the Plan does not have to pay for eye muscle revisions (67314) provided on October 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs therapy due to his high risk of
falls. The Plan denied your request. The Plan says that the patient's needs are custodial.
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 the enrollee's 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307) provided March 18, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the frequency of services billed exceeds the allowable.
The Plan must follow Medicare rules. Medicare rules say that providers may only perform and report one of three types of drug testing available per patient, per date of service. We looked at the file and Medicare rules. CPT code 80305 was billed for the same date of service. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307) provided March 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic radiology procedure provided on March 9, 2021.
You asked the Plan to waive the copayment for Magnetic resonance (eg, proton) imaging, brain (70553). You say that you do not agree with the amount being charged. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $110 copayment for Outpatient diagnostic tests. You have been asked to pay $110 copayment for Magnetic resonance (eg, proton) imaging, brain (70553). Magnetic resonance (eg, proton) imaging, brain (70553) falls within the Outpatient diagnostic tests 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 the diagnostic radiology procedure provided on March 9, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the care could be received in another setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The enrollee can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. There are no acute exacerbations of chronic medical problems. Her function is at or near her baseline and she can receive services at a lower 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01215) provided September 22, 2020.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the services billed.
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 01215 is not supported in the medical record. Specifically, the documentation does not
detail the start and stop time for the anesthesia. Based on this information, we decided that Medicare rules for
coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay
for anesthesia services (01215) provided September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to a LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, (A0428) provided on October 30, 2020.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport, (A0428). The Plan denied your request. The Plan says the member was transported from the hospital to the skilled nursing facility to maintain a safe sitting position. The vitals were stable. There is no indication of unstable conditions. There are alternate forms of transport that could have been used.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for ambulance service, basic life support, non-emergency transport, (A0428). Our reviewer says that the ambulance service, basic life support, non-emergency transport was not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 70-year-old male who was transported via ambulance from the hospital to a nursing facility. The enrollee was not inpatient at the time. She had difficulty maintaining a safe sitting position due to a C2 mass and posterior laminectomy. The enrollee's vitals were stable. There were no acute issues noted. The documentation does not support that other means of transport, namely a stretcher van, wound be contraindicated in this case. The documentation does not show that the enrollee required expertise or special equipment during transport to the nursing facility. Therefore, the documentation does not support that the ambulance services received were 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 ambulance service, basic life support, non-emergency transport, (A0428) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, (A0428) provided on October 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428) provided on February 9, 2021.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport (A0428). The Plan denied your request. The Plan says the ambulance transport was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for ambulance service, basic life support, non-emergency transport (A0428). Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the enrollee is a 64-year-old female who was transported via ambulance, via stretcher for a doctor's appointment due to weakness and oxygen dependence. Emergency medical services (EMS) determined the transport was low acuity and non-emergent. The transport was completed without incident and home oxygen level (3L) was provided. Other means of transport, namely stretcher van, were not contraindicated in this case. The documentation did not reveal the enrollee requiring any special equipment or expertise beyond her baseline home needs. Therefore, this request for ambulance services will be considered not medically necessary based on the documentation 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 ambulance service, basic life support, non-emergency transport (A0428) provided on February 9, 2021 have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428) provided on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.
You asked the Plan to pre-approve an office visit. You say that you have a rare cancer of the appendix. You also say that there are no other providers that can perform the procedure that you require. The Plan denied your request. The Plan says the requested services can be provided by a 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 an office visit to be provided by an OON provider