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

We decided that the Plan does not have to pay forthe ALS emergency ambulance (A0427) ground mileage (A0425) provided by "the provider" on June 3, 2019.You asked the Plan to pay forthe ambulance services. You say that please reconsider and reprocess the claim.The Plan denied your request. The Plan says the information provided does not support medical necessity for ambulance transport.Medicarepays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. 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 the ambulance services. Our reviewer says that this enrollee does not meet the medical necessary criteria for emergency ambulance transportation. Our physician reviewer found in this case, the enrollee reported diarrhea and abdominal pain. Vital signs were stable and physical examination non-concerning. The enrollee could have safely been transported for hospital evaluation by other means. Medical necessity is not supported.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 ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forthe ALS emergency ambulance (A0427) ground mileage (A0425) provided by "the provider" on June 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.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 the enrollee is currently undergoing treatment at an ACH for acute respiratory failure and chronic cholangitis. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee hada biliary drainage tube and a feeding tube placed. The enrollee appears to be tolerating ventilator weaning, her tube feeding and rehabilitative services. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 19, 2019 by out of network provider, "the provider". You asked the Plan to pay forphysician services. You say that if you had known that the provider was out-of-network you would have gone to someone else.The Plan denied your request. The Plan says the member does not have out-of-network benefits.Medicare rules saythat 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 has network providers available who can provide 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 forthe medical services provided on August 19, 2019 by out of network provider, "the provider".
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transcatheteraortic valve replacement services coded 33361 provided on August 13, 2019.You asked the Plan to pay forthe transcatheter aortic valve replacement services. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the services billed are missing required information.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 33361 is transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach.We find that CPT code 33361 is not supported in the medical record. Specifically, the clinical trial number was not billed on the claim. Per guidelines, the clinical trial number is a required item. Based on this information, we decided that Medicare rules for coverage of the transcatheter aortic valve replacement services have not been met.Therefore, we decided that the Plan does not have to pay forthe transcatheter aortic valve replacement services coded 33361 provided on August 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hemoglobin testing coded 83036 provided on August 8, 2019.You asked the Plan to pay forthe hemoglobin testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The hemoglobin testing at issue was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe hemoglobin testing coded 83036 provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint injection.You asked the Plan to pre-approve the facet joint injection services. You say that the enrollee has become bedridden and has lost endurance, which she has not been able to gain back without the requested services. You say that the enrollee is in great pain.The Plan denied your request. The Plan says the request for radio frequency is not medically necessary and cannot be approved at this time.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 the facet joint injection services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee hasdiabetes, chronic low back pain, received a lumbar fusion and also has degenerative disc and facet joint changes. She had intra-articular facet joint injection of steroid and local anesthetic at Right L5-S1. She did not have dual diagnostic MBBs performed. The degree and duration of pain relief from the intra-articular injection is NOT clearly documented. There is no documentation of the percentage pain relief and the duration of that pain relief. Dual diagnostic blocks which produce greater than 80% pain relief need to be performed before consideration of radiofrequency ablation.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 injection services have not been met.Therefore, we decided that the Plan does not have to pre-approvea facet joint injection.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen and pelvis (74177).You asked the Plan to pre-approve a CT of theabdomen and pelvis. You say that this is needed for restaging.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve a CT of the abdomen and pelvis. Our reviewer says that a CT of the abdomen and pelvis is not medically necessary at this time. Our physician reviewer found although a CT of the abdomen and pelvis is standard for the initial work-up of Stage I non-small-cell lung carcinoma, for follow-up guidelines states that a CT of the chest every 3 to 6 months for 3 years is standard. Routine screening with CT of the abdomen and pelvis is not standard. No justification is provided in the case records for a CT of the abdomen and pelvis.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 CT of the abdomen and pelvis have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography (CT) of the abdomen and pelvis (74177).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's servicesprovided on March 25, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's servicesprovided on March 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 10, 2019 by out of network provider, "the provider".You asked the Plan to pay forhome health services. You say that you would like these services reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services.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 has network providers available who can provide 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 forthe medical services provided on July 10, 2019 by out of network provider, "the provider".
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTaltz Injections 80MG/ML.You asked the Plan to pre-approveTaltz Injections. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Taltz injections are not covered under the enrollee's Medicare Part B benefit. The plan believes the enrollee's pharmacy benefit manager is "benefit manager". 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-approveTaltz Injections 80MG/ML.Benefits for Taltz Injectionsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessories -power tilt, custom fabricated seat cushions, headrest cushion and hardware.You asked the Plan to pre-approve the power wheelchair accessories. You say that the enrollee lives alone and requires 2 home health aides to assist with self-care and home care tasks. Without this power wheelchair the enrollee would be bed confined and unable to live alone.The Plan denied your request. The Plan says the records do not support that the power wheelchair accessories are 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 the power wheelchair accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation do not support that this enrollee is unable to perform a functional weight shift. There is no evidence of use of intermittent catheterization for bladder management or increased tone/spasticity. The documentation does not reveal that a standard (not custom) seat cushion and headrest cushion are unable to meet the enrollee'sneeds.
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 power wheelchair accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvepower wheelchair accessories -power tilt, custom fabricated seat cushions, headrest cushion and hardware
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have topre-approvea heavy duty wheelchair and accessories.You asked the Plan to pre-approvea heavy duty wheelchair and accessories. You say that because of medical conditions the enrollee needs a heavy duty wheelchair.The Plandenied your request. The Plan says there is no documentation that the enrollee's home provides adequate access between rooms, maneuvering space, and surfaces for use of the requested wheelchair.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The Home Assessment shows the rooms are not accessible by wheelchair. Based on this information, we decided that Medicare rules for coverage of a heavy duty wheelchair and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvea heavy duty wheelchair and accessories.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).You asked the Plan to pre-approve Procrit. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not tried and failed Retacrit as required by step-therapy rules.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 Procrit. Our reviewer says that the criteria for coverage of Procrit have not been met. Our physician reviewer found the Plan requires a trial of drug Retacrit before they will approve the requested drug. The documentation does not support that the patient tried and failed the required drug or that Retacrit (Epoetin alfa-epbx) would likely be less effective, or would likely have adverse effects for the enrollee 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 Procrit have not been met.Therefore, we decided that the Plan does not have to pre-approve Procrit (J0885)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153) provided on July 10, 2019.You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service is included in payment to the facility and not separately reimbursable for this provider in this placeof 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.We find that CPT code 99153 is not supported in the record. Specifically, 99153 is a "technical only" code and Medicare considers that the independent trained observer represents an expense to the facility and may only be billed by the facility. Based on this information, we decided that Medicare rules for coverage of the moderatesedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedures coded 97116, 97110, and 97112 provided from June 20, 2019 to August 13, 2019.You asked the Plan to pay forthe therapeutic procedures. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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, theCPT Code Manual definition of code 97116 is Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing). The CPT Code Manual definition of code 97110 is Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.The CPT Code Manual definition of code 97112 is Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.We find that CPT codes 97116, 97110, and 97112 are not supported in the medical record. Specifically, the documentation submitted did not support that at least 8 minutes were spent providing the gait training services. Therefore, code 97116 remains not supported. The documentation does not support that at least 8 minutes were spent providing the therapeutic exercises to develop strength and endurance, range of motion, and flexibility services. Therefore, code 97110 remains not supported. Lastly, the documentation does not support that at least 8 minutes was spent on neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.Therefore, code 97112 remains not supported.Based on this information, we decided that Medicare rules for coverage of the therapeutic procedures have not been met. Therefore, we decided that the Plan does not have to pay forthe therapeutic procedures coded 97116, 97110, and 97112 provided from June 20, 2019 to August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 64480) provided on August 30, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the add-on code was not billed with an acceptable primary procedure code.The Plan must follow Medicare rules. Medicare rules say that add-on codes can only be reported in addition to a primary procedure.When the CPT Manual identifies specific primary codes, the add-on code shall not be reported as a supplemental service for other HCPCS/CPT codes not listed as a primary code. Based on this information, we decided that Medicare rules for coverage of CPT 64480 have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 64480) provided on August 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRI provided by an out-of-network provider on June 19, 2019.You asked the Plan to pay for the MRI. The Plan denied your request. The Plan says there is no network deficiency for these services.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 has network providers available who can provide 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 forthe MRI provided by an out-of-network provider on June 19, 2019.