Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on January 16, 2019 through April 18, 2019.
You asked the Plan to pay for the home infusion therapy services. You say that this infusion code is not a DME and was not delivered to the member's home and the medication is delivered to the provider's office. The Plan denied your request. The Plan says S codes are not payable by Medicare and payment for this service, as billed, is not a covered benefit.
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 S9328 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, S9328 has a status code of I. This means that S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on January 16, 2019 through April 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (99292) provided April 12, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this 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 99292 is not supported in the medical record. Specifically, Current Procedural Terminology (CPT) code 99292 25 (2 units) remains not supported. This code represents an additional 30 minutes of critical care time in addition to the first 30-74 minutes of a critical care evaluation and management service (Current Procedural Terminology (CPT) code 99291). The submitted medical records document 60 minutes of critical care time. They do not support that an additional 60 minutes of critical care services was performed in addition to the first 30-74 minutes of a critical care evaluation and management service (Current Procedural Terminology (CPT) code 99291) to support the billing of Current Procedural Terminology (CPT) code 99292. It is noted that multiple attempts were made to contact the provider for additional information. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (99292) provided April 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle test strips for the enrollee.  You asked the Plan to pre-approve the strips. You say that this is medically necessary. The Plan denied your request. The Plan says this is a non-preferred diabetic supply.
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 strips. Our reviewer says that the requested strips are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation states the enrollee has diabetes mellitus and checks his blood glucose level once or twice daily. The preferred diabetic test strip are Accu-Chek and OneTouch. Documentation does not support this brand has been trialed or contra-indication to its use. Review does not support the prior-authorization criteria as outlined by the plan. Without the support of the documentation, an exception cannot be considered and medical necessity cannot be 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 strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle test strips for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 30, 2019 by an out-of-network provider.
You asked the Plan to pay for the out-of-network services. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.
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 file shows that the enrollee was seen for an office visit. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these out-of-network services. Therefore, we decided that the Plan does not have to pay for the office visit provided on August 30, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the eye exam, ophthalmic imaging and ophthalmoscopy provided on August 7, 2019.
You asked the Plan to waive the copayments for the eye exam, ophthalmic imaging and ophthalmoscopy. You submitted your bill for review. You say that you have never received invoices for these services. The Plan denied your request. The Plan says the copayments applied 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 $45 copayment for each covered specialist office visit and a $60 copayment for each covered diagnostic procedure or test at a network doctor's office.
You have been asked to pay a total of $105 for the eye exam, ophthalmic imaging and ophthalmoscopy.
Service
Allowed Amount
Standard Copayment
Member Liability
Eye exam
$146.05
$45
$45
Ophthalmic Imaging
$48.37
$60
$2.40
Ophthalmoscopy
$57.60
$60
$57.60
TOTAL:
$105
The eye exam falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The ophthalmic imaging and ophthalmoscopy fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered separate services. 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 eye exam, ophthalmic imaging and ophthalmoscopy provided on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 26, 2019 by the out of network provider.  You asked the Plan to pay for an office visit. You say that you would like these services to be approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are multiple in-network providers within 30 miles of the member's residence that could have rendered 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 for an office visit provided on February 26, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar microdiscectomy.
You asked the Plan to pre-approve these services. You say that the enrollee has a disc bulge and annular fissure at L5 to S1. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records do not show an imaging study that demonstrates significant compression of the nerves. There is no clear correlation between physical exam findings and the imaging studies. Spine discectomy surgery not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar microdiscectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99203 provided on September 18, 2019.
You asked the Plan to pay for the office visit. 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, the CPT Code Manual definition of code 99203 is Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99203 is not supported in the medical record. Specifically, this claim contains a new patient evaluation and management code when another evaluation and management code was billed within a three-year period. The new patient code is not allowed. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99203 provided on September 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 40 home health skilled nursing visits.
You asked the Plan to pre-approve the skilled nursing visits. You say that the records should support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet the medically necessary criteria for additional skilled nursing visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the skilled nursing visits. Our reviewer says that this enrollee does not meet the criteria for additional home health skilled nursing services. Our physician reviewer found that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the patient beyond the 10 additional visits which have been approved. The enrollee does not have complex wound care and 10 visits have been approved which would be adequate time for caregiver training to continue with non-complex wound 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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the 40 home health skilled nursing visits.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the computed tomography (CT) scans of the chest and of the abdomen/pelvis rendered on September 16, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that procedure codes 74177 and 71260 are included in approved code 78815.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that codes 74177 (abdomen/pelvis CT) and 71260 (chest CT) are not separately payable because they are included in code 78815 (PET scan); however, there are no active NCCI edits that disallow payment of codes 74177 and 71260 when billed with code 78815. The Plan has not provided any documentation or Medicare rules to support that codes 74177 and 71260 are not payable as billed. Therefore, we decided that the Plan has to pay for the computed tomography (CT) scans of the chest and of the abdomen/pelvis rendered on September 16, 2019.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
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's needs are too complex for skilled care. You say that the enrollee requires extended and acute-care level interventions provided by complex care trained staff, interdisciplinary treatment, ad team drive rehabilitation to resume reconditioning and improvement. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.
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 acute care hospital (ACH), having been admitted with altered mental status and a urinary tract infection, in the setting of advanced multiple sclerosis. The enrollee was intubated/ventilated and subsequently received a tracheotomy. She was apparently transferred to a medical floor with her tracheotomy, but returned to the ICU on February 2nd, following an episode of hemoptysis. The enrollee continues to exhibit an altered mental status and poor airway protective mechanisms. It does not appear that ventilator liberation or decannulation is planned. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time that 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 Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) following coronary bypass surgery, which was complicated by mediastinal hemorrhage. The enrollee was intubated/ventilated for her initial surgery and subsequently received a tracheotomy on January 30, 2020. As of February 4, 2020 the enrollee was tolerating CPAP settings during the day. 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. 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 for the enrollee.
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 these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you were treated for meningitis and a stroke. The note dated February 3, 2020 states that you are medically stable. The therapy note dated February 5, 2020 states that you had met your goals. The records do not show that you need an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not need an intensive therapy program in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tandem Autologous Stem Cell Transplant.
You asked the Plan to pre-approve the transplant. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Autologous Stem Cell Transplantation (AuSCT) is covered for the above indications. 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 transplant. Our reviewer says that Tandem Autologous Stem Cell Transplant is not medically reasonable and necessary. Our physician reviewer found that the enrollee has a diagnosis of choriocarcinoma. Review of the Medicare guidelines does not support an Autologous Stem Cell Transplant for the treatment of this diagnosis. Without the support of the documentation, medical necessity cannot be 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 transplant have not been met. Therefore, we decided that the Plan does not have to pre-approve Tandem Autologous Stem Cell Transplant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement power mobility device.
You asked the Plan to pre-approve a replacement power mobility device. You say that your current power wheelchair broke and could not be repaired. The Plan denied your request. The Plan says a repair was done in September, 2019 and the records do not show the device was damaged beyond repair.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you received a power mobility device on April 9, 2019. This power mobility device serves the same purpose as the requested power mobility device at issue and it is still under reasonable useful lifetime. Therefore, we decided that the Plan does not have to pre-approve a replacement power mobility device.