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

We decided that the Plan does not have to pay for injection services (CPT 62323, CPT 64493, CPT 64494, CPT 64495) provided to the enrollee on September 29, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do 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. 

In this case, the CPT Code Manual definition of the denied codes is:

CPT 62323: 

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal)

CPT 64493: 

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

CPT 64494: 

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, second level (list separately in addition to code for primary procedure

CPT 64495: 

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, third and any additional level(s) (list separately in addition to code for primary procedure)

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records Our physician reviewer found that in this case, each injection at the three levels were billed separately, each for two units. The bilateral modifier was not used. The requested coverage for 64493, 64494, 64495 cannot be recommended as billed. The record indicates that anesthetic agent was injected at the lumbar facets (transforaminal), not the interlaminar epidural or subarachnoid, lumbar or sacral space. CPT code 62323 cannot be recommended.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for injection services (CPT 62323, CPT 64493, CPT 64494, CPT 64495) provided to the enrollee on September 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure and pressure ulcer medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and 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.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the
enrollee does not require extensive or complex wound management, or a prolonged acute inpatient admission.
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 physician
reviewer found that in this case, the enrollee has a neuromuscular disorder. He was admitted to the acute care
hospital for acute on chronic hypoxic respiratory failure. As recent as May 18, he required urgent
bronchoscopy for mucous plugging and increased work of breathing. The enrollee continues to receive acute
care services that have not been denied. The medical record does not indicate that the enrollee require services
that the current facility cannot provide but that would be available at the LTACH.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

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. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. 

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 you do not meet the criteria for coverage. Our physician reviewer found the submitted records do not indicate that you frequently adjust your insulin regimen based upon results of glucose testing. The Medicare criteria for coverage are not met. The requested therapeutic CGM is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the detection test by nucleic acid for Chlamydia pneumoniae, infectious agent detection by nucleic acid; cytomegalovirus, detection test by nucleic acid for enterovirus, detection test by nucleic acid for legionella pneumophila, detection test by nucleic acid for Mycoplasma pneumoniae, detection test by nucleic acid for Staphylococcus aureus, detection test by nucleic acid for organism, and COVID-19 test provided on July 13, 2020.

You asked the Plan to pay for the laboratory services. You say that you have no knowledge of the enrollee's coverage prior to receiving the specimen at the laboratory. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the detection test by nucleic acid for Chlamydia pneumoniae, infectious agent detection by nucleic acid; cytomegalovirus, detection test by nucleic acid for enterovirus, detection test by nucleic acid for legionella pneumophila, detection test by nucleic acid for Mycoplasma pneumoniae, detection test by nucleic acid for Staphylococcus aureus, detection test by nucleic acid for organism, and COVID-19 test provided on July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is 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 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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the health plan's denial should be upheld. The enrollee does not require the intensity
of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen (15) hours
per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist office visit provided on August 7,
2020.
You asked the Plan to waive the copay for the specialist services. You say that the surgeon removed the wrong
thing. The Plan denied your request. The Plan says you are responsible for the copay when you receive covered
services.
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 $40
copay for each covered visit in an outpatient location with a specialist.
You have been asked to pay a $40 copay for each covered visit in an outpatient location with a specialist for the
specialist services. The services fall within the physician services 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 copay for the specialist office visit provided on August 7, 2020.
Your complaint that the surgeon removed the wrong thing is not a valid appeal for medical coverage. This part
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits and an ultrasound provided from November 13, 2020, and November 18, 2020.

You asked the Plan to waive the copayments for specialist visits and an ultrasound. You say that you feel that the visits should be considered post-operative. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $35 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay a $110 for ultrasounds.

You had a specialist visit on November 13, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment. 

You received an ultrasound on November 13, 2020. Therefore, you are responsible to pay the allowed amount of $63.50, which is less than the $100 copayment. 

You had a specialist visit on November 18, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment. 

The total amount you owe is: $133.50.

You have been asked to pay the total copayment amount of $133.50 for specialist visits and an ultrasound.

Specialist visits fall within the physician/practitioner services, including doctor's office visits benefit category. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for specialist visits and an ultrasound provided from November 13, 2020, and November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7210) to be performed by an oral surgeon.

You asked the Plan to pre-approve an extraction to be performed by an oral surgeon. You say that you need this to be performed by an oral surgeon because your tooth is fractured. The Plan denied your request. The Plan says services are only covered for participating general dentists.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested oral surgeon service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an extraction (D7210) to be performed by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for
the enrollee. The Plan denied your request. The Plan says rules for 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 there is no documentation provided necessitating admission to an 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 at the acute care hospital 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on January 14, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the drug testing. 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.
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 the drug testing provided on January 14, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Active Care bed.

You asked the Plan to pre-approve the Active Care bed. You say that your current bed is not functional, the railing does not come up on the side due to the mattress being bigger than the frame. You state the mattress will combat pressure and assist you to stand up and become more mobile. The Plan denied your request. The Plan says your current bed is not functional, and the railing does not come up on the side due to the mattress being bigger than the frame. You state the mattress will combat pressure and assist you to stand up and become more mobile.

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 Active Care bed. Our physician reviewer found the documentation does not support that you require an Active Care bed which is a rotating pivot hospital bed with mattress, and mobility bar for a need for an immediate or frequent change in body position or special attachments on an Active Care bed that cannot be fixed on an ordinary bed. The documentation does not reveal why you need the brand Active Care bed (rotating pivot hospital bed) with mattress and mobility bar as this bed is not proven to be safe or more effective than an alternative pressure relieving bed for your condition. Therefore, this request is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Active Care bed have not been met. Therefore, we decided that the Plan does not have to pre-approve Active Care bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 myocardial infarction and coronary artery bypass grafting. 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, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the chest x-ray provided on December 7, 2020.

You asked the Plan to waive the deductible for the chest x-ray. You say that this was ordered due to a COVID diagnosis but the claim does not indicate that diagnosis. You say that services completed because of COVID should be covered without member cost. The Plan denied your request. The Plan says the deductible applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services.

The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to basic imaging services. This cost sharing is a contractual obligation that had not been met at the time the chest x-ray was received on December 7, 2020. The records show the chest x-ray was ordered due to a diagnosis of pneumonia. Therefore, we decided that the Plan does not have to waive the deductible for the chest x-ray provided on December 7, 2020.