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

We decided that the Plan has to pay for home health care (S9124, 99199, S9122) provided from September 10, 2019 to January 30, 2020.
You asked the Plan to pay for home health services. You say that this was medically necessary. The Plan denied your request. The Plan says that this was custodial care.
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 pay for home health services. Our reviewer says that the services at issue were medically necessary. Our physician reviewer found the records show that you had significant mobility limitations following a non-traumatic intracerebral hemorrhage as well as a history of pressure ulcerations. The services of a skilled registered for medication management and skin care was reasonable as it appears you were home-confined due to your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to pay for home health care (S9124, 99199, S9122) provided from September 10, 2019 to January 30, 2020.
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the physician services provided on March 
16, 2020. 
 
You asked the Plan to waive the cost share for the physician services. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received physician services on the date of service at issue in this appeal. The 
Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $20 
copayment for Physician/Practitioner services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received physician 
services on March 16, 2020. You have been asked to pay a $20 copayment for the physician services. The 
physician services fall within the Physician/Practitioner 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 cost share for the physician services provided on March 16, 2020.
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 these services are medically necessary. The Plan denied your request. The Plan says that the member's current needs are being met in the acute setting.
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. The patient is currently undergoing treatment at an acute care hospital (ACH) for multifactorial respiratory failure. The enrollee was intubated/ventilated upon presentation and subsequently received a tracheotomy. Her hospital course has been complicated by tracheitis, agitation and ongoing fevers. Consequently, it does not appear that significant ventilator weaning has been attempted. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 95937 provided on December 16, 2019.
You asked the Plan to pay for CPT code 95937. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says CPT code 95937 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 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. Therefore, we decided that the Plan does not have to pay for CPT code 95937 provided on December 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Retacrit (40,000 units every 4 weeks).
You asked the Plan to pre-approve Retacrit. You say that Retacrit could help the enrollee to need fewer transfusions. The Plan denied your request. The Plan says the denial of authorization for Retacrit is correct, because the enrollee's iron saturation is less than 20% and ferritin is less than 100 milligrams per milliliter.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Retacrit. Our reviewer says that the enrollee does not meet the Medicare criteria for Retacrit. Our physician reviewer found the enrollee has anemia of chronic kidney disease, but also lab tests that are suggestive of some element of iron deficiency. Coverage criteria requires that the ferretin be above 100 and the iron saturation above 20%. The enrollee's levels are below this. The enrollee's iron should be repleted before Retacrit can be covered. Therefore, this service is not medically reasonable or 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 Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Retacrit (40,000 units every 4 weeks).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat Zilretta injection.
You asked the Plan to pre-approve the requested injection. You say that this medication gave you needed relief
from constant knee pain. The Plan denied your request. The Plan says the drug is not intended for repeat
administration.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA approved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 requested injection. Our physician
reviewer found that you have chronic left knee pain from chondromalacia and a meniscus tear. You received
prior steroid injections and then Zilretta and achieved 5 months of pain relief. The label specifically states the
requested drug is for one time use only. Therefore the request is considered not medically reasonable or
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 requested injection have not been met. Therefore, we decided that the Plan
does not have to pre-approve a repeat Zilretta injection.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that you feel that the enrollee requires care in 
the SNF setting. The Plan denied your request. The Plan says the documentation shows that the enrollee is 
stable with no daily skilled service needs. 
 
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 SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 89-year-old 
female with DVT, dementia, diabetes, glaucoma, depression and PVD admitted to the hospital. From a nursing 
perspective, the beneficiary received oral and ophthalmic medications. The beneficiary had stable vital signs. 
She was treated for a UTI. Regarding rehabilitation services, the beneficiary received PT, ST and OT and was 
discharged from services in the SNF prior to re-hospitalization. The beneficiary was at a supervision/touch 
assist to contact guard assist level with functional mobility including gait to 150 feet with a rolling walker. The 
beneficiary required varying assist with ADLs. She tolerated a mechanical soft diet and thin liquids. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
This beneficiary 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician services provided on April 13, 2020.
You asked the Plan to waive the copayment for the physician services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received services provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 copayment for services provided by a specialist. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist on April 13, 2020. You have been asked to pay a $30.45 copayment for the specialist services, which is less than the contracted $40 copayment amount. The specialist services fall within the Physicians/Practitioner 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 copayment for the physician services provided on April 13, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. You say that the enrollee is not being engaged mentally, 
which is causing him to decline. The Plan denied your request. The Plan says the medical records do not 
support that the enrollee has any skilled needs or acute medical issues. 
 
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. 
 
The documentation shows that continued SNF services beyond August 8, 2020, were requested for 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 continued services. Our physician 
reviewer found that from a nursing perspective, the enrollee received oral medications and had stable vital 
signs. There are no identifiable skilled nursing service needs. Regarding rehab services, by the date in question, 
the enrollee was at a minimal to moderate assist level with functional mobility. He required varying assist with 
activities of daily living. There are no identifiable skilled therapy service needs. He does not require skilled 
nursing or therapy services on a daily basis. The enrollee do not meet severity of illness or intensity of service 
criteria for an inpatient basis in a SNF 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skin testing (95004) provided on May 2, 2019. 
 
You asked the Plan to pay for skin testing. You say that this was documented in the records. The Plan denied 
your request. The Plan says the records do not show skin testing was performed. 
 
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 95004 is percutaneous tests (scratch, puncture, prick) 
with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of 
tests. 
 
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 skin testing. Our reviewer says that the 
billing of this code is not supported. Our physician reviewer found the medical records do not clearly document 
that percutaneous tests with allergenic extracts, immediate type reaction, including test interpretation and report 
took place. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin testing have not been met. Therefore, we decided that the Plan does not 
have to pay for skin testing (95004) provided on May 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you need more time to get stronger. The Plan denied your request. The Plan says you do not require daily skilled services on an inpatient basis.
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 SNF services. Our physician reviewer found that from a nursing perspective, you received oral medications, wound care, and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a standby assist level with functional mobility. You require varying assist with activities of daily living. Although there are 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 SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the shoulders for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that the provider must show medical need before this request is approved.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the records show bilateral arm weakness and tingling. These symptoms could reflect shoulder pathology however the nature of the enrollee's November 2019 fall is bothersome. She fell and landed on her face which in effect results in hyperextension. While no fracture is evident on the x-rays by report, cervical spine pathology is not excluded. In a patient with bilateral upper extremity weakness and tingling, possibly due to shoulder pathology, physical therapy will be challenging at best. Prior to addressing her shoulders it is reasonable to rule out cervical spine disease as the cause of her cervicalgia and bilateral upper extremity symptoms. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the shoulders for the enrollee.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 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 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 you required minimal assistance to walk 12 feet with a wheeled walker. You required minimal to moderate assistance with transfers. You required maximum assistance for lower body dressing. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that your functional status requires an 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cleaning and sanitizing system for a continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve these services. You say that you need the sanitizing machine to uphold the appropriate level of sanitizing for the CPAP. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a cleaning and sanitizing system for a continuous positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 85060 provided on February 20, 2020.
You asked the Plan to pay for CPT code 85060. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the professional component of this procedure is only payable for inpatients. The services were billed with an outpatient place of service. Payment for this service cannot be made for hospital outpatients. Based on this information, we decided that Medicare rules for coverage of CPT code 85060 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 85060 provided on February 20, 2020.