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

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says home health aide visits for bathing are not a covered benefit.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 the requested services are not medically reasonable or necessary. Our physician reviewer found the requested services do not meet the home health aide services per Section 50.2. The guidelines state that you must be receiving skilled therapy or skilled nursing services in the home to receive home health aide services. The documentation does not reveal that you were recertified for skilled nursing services therefore the request for home health aide services is not reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. 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 pre-approve home health services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 23473, CPT 24515) provided on September 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
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 23473 is "Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component". The CPT Code Manual definition of code 24515 is "Open treatment of humeral shaft fracture with plate/screws, with or without cerclage". We asked our coding 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 use of CPT codes 23473 and 24515 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation of a "Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component" being performed on September 24, 2019, therefore, this service cannot be verified. The required description is not included in the operative note in the enrollee's medical record. Additionally, the medical records submitted do not include documentation that an "Open treatment of humeral shaft fracture with plate/screws, with or without cerclage" was performed as a separately identifiable procedure, unrelated to the primary procedure performed. Although modifier 59 is allowed to unbundle this procedure, the documentation in the medical record must support the appropriate use of the 59 modifier. In this case, it is inappropriate to submit CPT 24515 for separate reimbursement. We looked at this coder'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 the services (CPT 23473, CPT 24515) provided on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care provided on July 1, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service exceeds the maximum number allowed per day.
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 99236 is observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date. We find that the maximum number of units for the provided service has already been billed and paid for by the plan. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the observation care provided on July 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the eyelid surgery(67961) provided on January 24, 2020.You asked the Plan to adjust the copayment for this service. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the copayment was applied correctly to the service provided.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 $200 copayment for care provided in a certified ambulatory surgical center. You have been asked to pay a $200 copayment for the eyelid surgeryprovided by the ambulatory surgical center. 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 adjust the copayment for the eyelid surgery(67961) provided on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder orthosis rendered on December 11, 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 the services are not covered.
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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee is reported to have left shoulder pain. No detailed history, associated symptoms, review of systems or physical examination has been documented. There is no evidence of diagnostic evaluation (i.e. x-rays) or prescription therapy provision/response (i.e. prescription meds, injections, physical or occupational therapy). Therefore, the documentation does not support the medical necessity or reasonableness of the provided service. 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 pay for the shoulder orthosis rendered on December 11, 2019.
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 to be cared for at a lower level. You say that the enrollee has exceeded her current stay and this would be the next appropriate level of care in the continuum of that care. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of LTACH care. The Plan says that the services needed by the enrollee can be provided in another 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. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a perforated duodenal ulcer. The enrollee was intubated/ventilated, but has since been extubated and is no longer on a ventilator. There is no evidence that the enrollee requires services that are not currently available. 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on January 28, 2020.You asked the Plan to waive the copayment for laboratory tests. You say that you paid the $45 specialist copayment and disagree with the charges.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 $10 copayment for lab tests. You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests fall 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 for laboratory tests provided on January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on June 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-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 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 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 services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on June 24, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on September 19, 2019.
You asked the Plan to pay for the services provided. You say that you want to void the paid code. The Plan denied your request. The Plan says the service was billed with another evaluation and management service on the same day.
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 99285 is emergency department visit for the evaluation and management of a patient. We find that an evaluation and management service was previously billed and paid for by the Plan. Two evaluation and management visits billed on the same day is not payable. There is no documentation provided to show that the previously paid service has been voided. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit provided on September 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. The Plan denied your request. The Plan says IRF care is not medically necessary. The Plan says that any continued medical needs can be met at a lower level of care.
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 the enrollee was medically stable with no evidence of a need for supervision by Physical Medicine and Rehabilitation Physician. There is no evidence of a need for acute rehab nursing care. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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 waive the coinsurance for DME provided from March 7, 2019 to September 7, 2019.
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges. 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 20% coinsurance for DME and related supplies. You received DME from March 7, 2019 to September 7, 2019. The total allowed amount is $1,556.10 and 20% of that is $311.22. You have been asked to pay the total coinsurance amount of $311.22 for DME. DME falls within the DME and related 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 coinsurance for DME provided from March 7, 2019 to September 7, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for anesthesia services provided to the enrollee on November 4, 2019.
You asked the Plan to pay for the services. You say that you called to confirm the provider was in-network. The Plan denied your request. The Plan says that the provider was not in-network.
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. According to the case file, it appears that you were told that the provider who rendered the services at issue in this case was in-network with your plan. The plan has not substantiated their denial in this case, as they have not addressed this claim. If you were told that the provider was in-network, you should be held harmless for these services. Therefore, we decided that the Plan has to pay for anesthesia services provided to the enrollee on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery services (CPT 67500) provided to the enrollee on December 3, 2019.

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 this surgical code was submitted by a provider with an anesthesia specialty.

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 67500 is "Retrobulbar injection; medication (separate procedure, does not include supply of medication)"

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 coded correctly. Our physician reviewer found the retrobulbar block was not performed by the surgeon and, therefore, is not considered part of the global surgery code. The retrobulbar block was performed by the anesthesia service, who also provided anesthesia monitoring during the procedure. Therefore, the injection is considered part of the anesthesia service, not a stand-alone procedure, and should be billed with an anesthesia code (00100-01999), not a stand-alone procedure code (CPT 67500). The billing of CPT 67500 is not supported.

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 surgery services (CPT 67500) provided to the enrollee on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa. You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary. The Plan follows Medicare rules. Medicare rules say that Euflexxa is only covered for certain 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 Euflexxa. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has unilateral primary osteoarthritis. The documentation does not support that is has been longer than six months since the previous injection. More time is needed in between injections. Therefore, the enrollee does not meet criteria for the requested 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 23, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the laboratory services rendered on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transtelephonic rhythm strip pacemaker evaluation (93293) provided on November 26, 2019. You asked the Plan to pay for the evaluation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this code must be submitted with the 26 modifier to indicate the professional component in a Part A stay. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 93293 is not supported in the record. Specifically, the record indicates that the member is in POS 31, or a Skilled Nursing Facility. The technical component of a service rendered to a member in a Part A Skilled Nursing Facility stay will only be paid to the facility. In this case, CPT code 93293 has been billed globally. This code requires the 26 modifier to indicate the professional component of the service.  Based on this information, we decided that Medicare rules for coverage of the evaluation have not been met. Therefore, we decided that the Plan does not have to pay for transtelephonic rhythm strip pacemaker evaluation (93293) provided on November 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent for the enrollee.You asked the Plan to pre-approve Dupixent. The Plan denied your request. The Plan says that this is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Dupixent for the enrollee.Benefits for Dupixentmay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.