Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pelvic exam/cancer screening (G0101) provided April 7, 2021.

You asked the Plan to pay for the screening services. You say that you are appealing the denied claim as this is an exam that you have every year. The Plan denied your request. The Plan says the maximum allowed number of covered visits under the benefit has been exceeded.

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 Pap tests and pelvic exams are covered once every 24 months. If you are at high risk of cervical or vaginal cancer or you are of childbearing age and have had an abnormal Pap test within the past 3 years, then one Pap test every 12 months. 

This screening is covered once every 24 months and once every 12 months if you are of high risk. The records show that this service was last provided March 12, 2020. The plan had confirmed that with the provider that you are not high risk. Therefore, this benefit visit limit has been exceeded. Therefore, we decided that the Plan does not have to pay for the pelvic exam/cancer screening (G0101) provided April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on March 16, 2021.
You asked the Plan to waive the copayment for the breast ultrasound (76641). You say that you were advised that an annual mammogram with an ultrasound is preventative and covered. 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 a $60 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $60 copayment for the breast ultrasound (76641). The breast ultrasound (76641) 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 breast ultrasound provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare does not pay for hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that Customers are required to contact the Plan's hearing vendor to access the routine hearing exam and supplemental hearing aid benefits. Supplemental routine hearing services and hearing aids are not covered Out-of-Network. You can find this information on page 48 of the Plan's 2021 Evidence of Coverage.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 48 additional trips.

You asked the Plan to pre-approve the additional trips. You say that you are a fall risk patient. You say that you use a wheelchair but still have difficulty getting around. You say that you do not have funds to use door to door transportation service. You also say that you need 48 more rides (round trip) to cover you for the remainder of the year. The Plan denied your request. The Plan says that the 48 additional trips would exceed the calendar year benefit of 52 one-way trips per year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 52 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the requested for an additional 48 trips would exceed the Plan maximum benefit for coverage of routine transportation. The record shows that you have used 29 one-way trips with 23 one-way trips remaining. Therefore, we decided that the Plan does not have to pre-approve 48 additional trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee was admitted for a stroke. Medical problems are
stable. There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary
rehabilitation program.

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: 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 you need additional therapy and it is not safe for you to go home. The Plan denied your request. The Plan says that there are no daily skilled nursing needs.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care from August 16, 2021, forward. 
 
You asked the Plan to pre-approve inpatient hospital care from August 16, 2021, forward. You say that the 
requested inpatient hospital care from August 16, 2021, forward is medically necessary. The Plan denied your 
request. The Plan says the requested inpatient hospital care is 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 inpatient hospital care from August 16, 
2021, forward. Our reviewer says that the requested inpatient hospital care is not medically necessary. Our 
physician reviewer found the review indicates that the enrollee was evaluated in the emergency room for the 
evaluation of anemia. She was evaluated and discharged the same day followed by imaging and endoscopy. 
She presented with anemia with no chest pain or shortness of breath. Her vital signs and blood oxygen levels 
were normal. She did not have dizziness or syncope. She had a normal EKG and chest x-ray and her blood 
pressure was normal. She received two units of packed red blood cells and furosemide. She required no 
inpatient diagnostic studies or therapeutic interventions. The review has determined that the requested inpatient 
hospital care from August 16, 2021, forward is not medically reasonable and necessary 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 inpatient hospital care from August 16, 2021, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care from August 16, 2021, 
forward.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (1HB11, G0151, Q5004) provided 
March 9, 2020 to April 7, 2020. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been 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 find that CPT code 1HB11, G0151, & Q5004 is not supported in the medical record. Specifically, the claim 
was not billed with a correct "Q" code for the place of service. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan oes not have to pay for home health services (1HB11, G0151, Q5004) provided March 9, 2020 to April 7, 
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for respiratory failure, sepsis and perforated intestine. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the computed tomography (CT) scan of the abdomen and the CT scan of the chest you had on November 20, 2020.
You asked the Plan to waive the copayments for the CT scans. You say that your doctor ordered these tests for you and no one can explain what these charges are for. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan also says that other services you addressed in your appeal letter will be handled separately by them.
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 $125 copayment for each Medicare-covered radiological diagnostic service. You have been asked to pay a $125 copayment for each of the CT scans. The CT scans falls within the each
Medicare-covered radiological diagnostic service benefit category and your Evidence of Coverage states that this copayment is charged per test. 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 copayments for the computed tomography (CT) scan of the abdomen and the CT scan of the chest you had on November 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 you do not require skilled nursing or therapy services on a daily basis or at an inpatient level in a skilled nursing facility. 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. Specifically, medically necessary services can be obtained with a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the levocarnitine injection coded J1855, the thiamine hcl injection coded J3411, the pyridoxine hcl injection coded J3415, and the unclassified drug coded J3490 provided on October 13, 2020.

You asked the Plan to pay for the levocarnitine injection, the thiamine hcl injection, the pyridoxine hcl injection, and the unclassified drug. 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. 

We find that CPT codes J1955, J3411, J3415 and J3490 are not supported in the medical record. Specifically, the documentation submitted does not support the 8 units billed of code J3490.

In addition, the documentation indicates that Bupivacaine Hydrochloride was administered in compounded
form through an implantable pump and reservoir. There is a more appropriate code to be billed for these services. 

The documentation submitted does not include documentation of injection, thiamine HCl, 100 mg. The medical records indicate that drug in compounding form was administered. Code J3411 is not supported by the documentation and there is a more appropriate code to be billed for the services rendered. 

The documentation submitted did not include documentation of Injection, pyridoxine HCl, 100 mg. The medical records indicate that drug in compounding form was administered. Code J3415 is not supported by the documentation and there is a more appropriate code to be billed for the services rendered. 

The documentation submitted does not support the 8 units billed of code J3490. Only one unit is appropriate to bill for this code. In addition, the documentation indicates that Bupivacaine Hydrochloride was administered in compounded form through an implantable pump and reservoir. There is a more appropriate code to be billed for the services rendered. 

Based on this information, we decided that Medicare rules for coverage of the levocarnitine injection, the thiamine hcl injection, the pyridoxine hcl injection, and the unclassified drug have not been met. Therefore, we decided that the Plan does not have to pay for the levocarnitine injection coded J1855, the thiamine hcl injection coded J3411, the pyridoxine hcl injection coded J3415, and the unclassified drug coded J3490 provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a respiratory assist device (E0470), and a humidifier (E0562).
You asked the Plan to pre-approve a respiratory assist device and a humidifier. You say that the items are
medically necessary. The Plan denied your request. The Plan says that this device has been given within the
past five years and all issues pertaining to replacement due to possible damage need to be handled through the
DME provider. Although there was a recall on the machine, you are still able to use the BiPap device.
The Plan must follow Medicare rules. Medicare rules say that the MAO is responsible for maintaining
continuity of care for its enrollee by ensuring uninterrupted access to the medically necessary covered DME
item, including when the item needs to be repaired or replaced. If necessary, the MAO must purchase or rent a
replacement item for the beneficiary to use.
We looked at your request and the Medicare rules. Based on this information we determined that Medicare
coverage criteria have been met. Specifically, the record indicates that the member has registered with the
supplier, but there has been no resolution. It is the burden of the Health Plan to ensure uninterrupted access to
medically necessary covered DME. Therefore, we decided that the Plan has to pre-approve a respiratory assist
device (E0470), and a humidifier (E0562).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. Functionally at the current level, the enrollee will not be able to meet Medicare requirements in an IRF given that she needed assist at baseline before admission to the hospital.

While she would benefit from physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. IRF admission is not medically necessary based on lack of medical complexity or identified skilled rehab nursing needs and dependent functional level. The enrollee's rehab needs can be easily and safely met at a less intense and alternate 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on February 1, 2021.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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 in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36523 to support their denial. However, LCD L36523 is not valid for the provider's billing state of Texas. Therefore, we are unable to use LCD L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on February 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on January 14, 2021.

You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. 

In this case, the CPT Code Manual definition of code 71045 is radiologic examination, chest; single view. 

We find that CPT code 71045 is not supported in the medical record. Specifically, this service was billed without an appropriate modifier. The documentation shows that the enrollee was in a skilled nursing facility setting for this date of service. Code must be submitted with a modifier of 26 to indicate "professional component" in a Part A stay. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on January 14, 2021.