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

We decided that the Plandoes not haveto pre-approvecontinued admission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe information submitted does not support the need for daily skilled nursing or daily skilled therapy.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (74176, 71250, 70450, and 72125) provided on July 12, 2019.You asked the Plan to pay for imaging services. You say that these services should be covered.The Plan denied your request. The Plan says this claim was billed with an incorrect diagnosis code order.The Plan must follow Medicare rules. Medicare rules say that observation codes are to be used as principal diagnosis only. We looked at the file and Medicare rules. The record shows that this claim was billed with Z04.3, an observation code, not listed as the primary diagnosis. Based on this information, we decided that Medicare rules for coverage of imaging services have not been met.Therefore, we decided that the Plan does not have to pay forimaging services (74176, 71250, 70450, and 72125) provided on July 12, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
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 step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of unspecified chronic kidney disease and unspecified anemia. He has not tried and failed the plan's required drug of Retacrit. The records do not show that Retacrit would be less effective or contraindicated; therefore, Aranesp is not reasonable or 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 Aranesp for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 25, 2019.
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 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 G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from July 16, 2019 through July 19, 2019.You asked the Plan to waive the copayment forthe inpatient stay. You say that you were informed the total cost would be $279. You say that the bill should be corrected.The Plan denied your request. The Plan says the copayment 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 $300 per day, days 1-6 for each in-network inpatient stay.You have been asked to pay a $900 copayment for the inpatient stay. ($300/day x 3 days = $900). The inpatient stay falls within the "Inpatient hospital care" 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 forthe inpatient stay provided from July 16, 2019 through July 19, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Supartz knee injections.You asked the Planto pre-approvethe Supartz injections. You say that the enrollee needs this injection for treatment of her arthritis pain.The Plandenied your request. The Plansayssince there is no reason that Orthovisc or Monovisc cannot be used, the requested Supartz is correctly denied.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 the Supartz injections. Our reviewer says that the requested drug is not considered reasonable and necessary based on step therapy criteria. Our physician reviewer found the enrollee is a 78-year-old woman with adiagnosis of Unilateral primary osteoarthritis of the right knee. There is no evidence of a trial and failure of the preferred drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, and/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 the Supartz injections have not been met.Therefore, we decided that the Plandoes not haveto pre-approveSupartz knee injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria, and pertussis (TDaP) vaccine rendered to you on June 20, 2019.You asked the Plan to pay forthese services. You say that the services should be covered because the provider gave the vaccine.The Plan denied your request. The Plan says the vaccine is not covered.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services.Therefore, we decided that the Plan does not have to pay forthe tetanus, diphtheria, and pertussis (TDaP) vaccine rendered to you on June 20, 2019.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography provided on May 8, 2019.You asked the Plan to waive the copayment for the echocardiography. You say that you did not want this procedure. You say that you were informed you would not have to pay.The Plan denied your request. The Plan says the copayment 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 a $35 copayment for each Medicare-covered diagnostic procedures and tests at an in-network specialist's office.You have been asked to pay a $35 copayment for the echocardiography. The echocardiography 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 copayment forthe echocardiography provided on May 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99190) provided to "the beneficiary" on July 26, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment for this service would be included in the Part A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99190) provided to "the beneficiary" on July 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no expectation that further therapywill provide any significant and sustainable functional improvement.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe sedation services rendered on July 23, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99152 is not supported.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 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not contain documentation of the presence of an independent trained observer to assist with monitoring the enrollee's consciousness. 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 pay forthesedation services rendered on July 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond January 13, 2020.
You asked the Plan to pre-approve the continued inpatient care. You say that ongoing care in the inpatient setting is necessary. The Plan denied your request. The Plan says the enrollee is stable and can be treated in partial hospitalization or another less restrictive setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient care. Our reviewer says that the documentation does not support that continued inpatient psychiatric care is medically reasonable and necessary. Our physician reviewer found the enrollee was admitted to inpatient care on December 24, 2019 with Major Depressive Disorder and Generalized Anxiety Disorder. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was able to go off the unit but came back with her son. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others. The health plan's denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and
did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. 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 continued inpatient care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by out of network (OON) provider.You asked the Planto pre-approve the OON chiropractic services. You say that you have neck pain due to herniated discs and the physician is able to relieve this pain. You have tried a network chiropractor but were not getting any relief. You feel that the OON provider should be approved as she is the only one who has been able to relieve your pain.The Plandenied your request. The Plansaysthere are network chiropractors with equal credentials. There is no need for an OON referral for care that is available within the network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvechiropractic services to be provided by out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99205) provided on July 5, 2018 by out of network provider, "the doctor".You asked the Plan to pay foran office visit. You say that you are appealing the claim that denied for no authorization and no referring provider. You say that you requested documents and never received the original fax.The Plan denied your request. The Plan says the services are not authorized because "the doctor" is a non-network provider who does not work with the member's health plan, and the member was referred by "referring doctor", who also does notwork with the member's plan. The member's primary care physician did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for anout-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 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 foran office visit (99205) provided on July 5, 2018 by out of network provider,"the doctor".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on August 19, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment for this service would be included in the Part A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99190) provided on August 19, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve3D radiation planning with image-guided radiation therapy (IGRT).You asked the Planto pre-approvethe 3D conformal planning and IGRT. You say that this type of radiation planning and treatment is needed in order to avoid certain "hot spots" and provide sufficient radiation dose to the brain mets.The Plandenied your request. The Plansaysthe documentation does not show why the necessary treatment cannot be done with standard radiation treatment planning.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 3D conformal planning and IGRT. Our reviewer says that the requested radiation treatments are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 69 year old male with multiple brain metastases from non-small cell lung cancer who is being offered whole brain radiation as treatment. For whole brain radiation for of brain metastases --even when a CT scan is used for treatment planning purposes, and when a 3D dose matrix generated --for billing purposes, it is the accepted standard to bill 2D radiation and not 3D radiation. Likewise, it is not standard to bill for IGRT. Generally, 3D radiation is necessary when the 2D radiationplan results in unacceptable normal tissue dose exposure and toxicity risks (uncommon with palliative treatment). It usually implies the need to spare normal tissues in a manner that cannot be achieved with 2D radiation. The need for 3D radiation has not been substantiated in this case and that it would be within accepted standards of care to use 2D radiation.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 3D conformal planning and IGRT have not been met.Therefore, we decided that the Plandoes not haveto pre-approve3D radiation planning with image-guided radiation therapy (IGRT)
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on September 11, 2018.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 procedure codes 95908 and 95885 are not supported.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 95908 is nerve conduction studies; 3-4 studies. The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure).We find that CPT codes 95908 and 95885 are not supported in the medical record. Specifically, the documentation shows that the monitoring was triggered by electromyography, which does not support code 95908. Code 95885 is an add-on code and given that the primary code 95908 is not supported, the add-on code is also not supported. 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 pay forthe services rendered on September 11, 2018.