Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services provided on January 13, 2021, billed with code 99223.
You asked the Plan to pay for the EM services as billed. You say that this code is supported and should be paid. The Plan denied your request. The Plan says it is not supported for this level of EM code to be paid.
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 99223 is Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. We asked our coder 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 EM services as billed. Our reviewer says that this code is not supported. Our reviewer found the records provided are not sufficiently detailed to confirm that a comprehensive history/examination were provided, nor that the medical decision making was of high complexity. 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 EM services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services provided on January 13, 2021, billed with code 99223.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99203) and acupuncture, one or more needles; without electrical stimulation, initial 15 minutes (97810) for the left foot.
You asked the Plan to pre-approve the acupuncture services. You say that you had left foot bunion surgery on December 16, 2020 and still have ongoing pain and difficulty walking, centered on the ball of your left foot. You would like to consider conservative treatment instead of future surgery. The Plan denied your request. The Plan says acupuncture treatment is only covered for chronic low back pain and any other condition other than for chronic low back pain is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, you are seeking acupuncture treatment for your left foot. Acupuncture is only covered for the treatment of low back pain. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visit (99203) and acupuncture, one or more needles; without electrical stimulation, initial 15 minutes (97810) for the left foot.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies, adult sized disposable incontinence product, protective underwear/pull-on, large size (T4527).
You asked the Plan to pre-approve incontinence supplies. You say that you are appealing the denial for the incontinence supplies. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, adult sized disposable incontinence product, protective underwear/pull-on, large size (T4527).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).

You asked the Plan to pre-approve the Dexcom G6 brand CGM. You say that this brand is necessary due to the features which will help his caregivers monitor his blood glucose levels. The Plan denied your request. The Plan says there is no evidence that the Freestyle Libre does not meet his needs.

The Plan follows Medicare rules. Medicare rules say that Plans are allowed to limit DME coverage to specific brands as long as non-preferred brands are covered when proven to be 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 Dexcom G6 brand CGM. Our reviewer says that the documentation does not support that the non-preferred brand is medically necessary. Our physician reviewer found the enrollee has had difficult to control diabetes, though his most recent A1C is 6.5%. Freestyle Libre is the preferred continuous glucose monitor for your plan. Nonpreferred CGMs are covered for enrollees 17 years old or younger, 75 years old or older, who use an insulin pump, or have a medical reason why Freestyle Libre cannot be used. There is not sufficient evidence in the documentation to support that the requested non-preferred brand CGM is medically reasonable and necessary over the preferred brand.

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 Dexcom G6 brand CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
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 it is felt that SNF care would benefit the 
enrollee's recovery. The Plan denied your request. The Plan says the enrollee's needs can be met with less than 
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 in the Medicare rules section 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 enrollee is a male who was 
electively admitted to the hospital for a right-sided total hip replacement. He had post-op anemia with a 
gastrointestinal hemorrhage requiring a blood transfusion but has stabilized and is ready for discharge. The 
most recent therapy documentation indicates the member is able to ambulate up to 75 feet with a front wheel 
walker and contact guard assistance. He is able to transfer and accomplish bed mobility without hands-on 
assistance. 
 
The member has stabilized medically and is ready for discharge from the hospital.  The member does not 
require skilled nursing and/or skilled therapy services on a daily basis.  He is medically stable and can receive 
further rehab services at a lower level of care.  Although further rehab services would be appropriate to 
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care 
than a skilled nursing facility.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar for the shower.
You asked the Plan to pre-approve a grab bar. You say that you are not able to enter the shower without a bar to hold onto for balance. You feel that this should be covered. The Plan denied your request. The Plan says this is not a covered item under Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar for the shower.
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 believe that you need care in a SNF to meet your needs. The Plan denied your request. The Plan says you do not require daily skilled nursing or therapy services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 enrollee is a male with a history of lung cancer who was admitted to an acute care hospital and diagnosed with delirium. His family chose to continue with comfort care. The most recent therapy documentation indicates the member is able to ambulate up to 250 feet without hands on assistance. He requires set-up for eating and is able to toilet, transfer and accomplish bed mobility without hands-on assistance. The member is medically stable and does not have any complex daily wound care, intravenous medications or required care for a feeding tube. The member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Novolog 100 Unit/ML Vial (CPT code J1815).
You asked the Plan to pre-approve the medication. You say that you need a tier exception to be able to afford the medicine. The Plan denied your request. The Plan says you asked for a covered drug at a lower cost level. The Plan states when you ask for a higher cost drug at a lower cost level (tier) it is called a tiering exception. The Plan states tiering exceptions are only available for drugs billed on the Part D (Pharmacy) benefit and you are asking for Part B (Medical) benefit coverage; therefore, the drug you requested is not eligible for a tiering exception.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medication have not been met. This drug/device is covered by Medicare Part B.
Medicare rules say tier exceptions (co-pay reductions) are not available for drugs/devices covered by Part B. Medicare also says drugs/devices covered by Part B can't be covered by Part D. Therefore, we decided that the Plan does not have to pre-approve Novolog 100 Unit/ML Vial (CPT code J1815).
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 LTACH is clinically appropriate in terms of type of care, frequency, extent, site, and duration of the enrollee's illness. You say that the LTACH is better suited to meet the needs of someone like the enrollee, whose multifaceted issues will require an interdisciplinary approach to help him achieve his baseline. You say that the criteria for coverage of LTACH care have been met. The Plan denied your request. The Plan says it is not safe for the enrollee to leave the current hospital at this time.
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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromonitoring services provided during surgery on February 23, 2021, billed with codes 95908, 95927, 95937, and 95955.

You asked the Plan to pay for the services as billed. You say that these codes are supported and should be paid for this medically necessary monitoring service. The Plan denied your request. The Plan says these codes are incorrectly reported for the services rendered.

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 95927 is Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head. The definition of code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. Lastly, the definition of 95955 is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery).

We asked our coder 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 as billed. Our reviewer says that the documentation does not support the billing of these codes. Our reviewer found CPT 95908 is not supported by the technical report. The technical report does not include documentation of "interpretation of numerous test results, using well-established techniques to assess the amplitude, latency, and configuration of wave forms elicited by stimulation at each site of each nerve tested", as required per CPT guidelines. The report also does not include documentation of somatosensory-evoked potential in the head or trunk. For code 95937, the report does not document repeated electrical stimulation of a motor nerve and measuring the size of the summated electrical response of the excited muscle fibers. Therefore, this procedure cannot be confirmed. For code 95955, the report states "EEG was symmetric throughout the procedure. No lateralizing events were observed during this case". This service is reimbursed through code G0453 which was paid on this claim.

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 as billed have not been met. Therefore, we decided that the Plan does not have to pay for the neuromonitoring services provided during surgery on February 23, 2021, billed with codes 95908, 95927, 95937, and 95955.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (CPT code J0585), for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication has helped the enrollee significantly. The Plan denied your request. The Plan says the drug is not being prescribed for a medically accepted indication.
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 medication. Our physician reviewer found the review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox (CPT code J0585), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond August 26, 2021.
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee is not ready to be discharged from the SNF. The Plan denied your request. The Plan says the enrollee's needs can be met with less than daily skilled services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male who was admitted to the hospital after a fall with a right knee effusion. He did not have any significant injuries. He was admitted to a skilled nursing facility on 8/16/21 for rehab services. The most recent therapy documentation indicates the member continues to require assistance with self-care tasks and mobility. He has intermittent worsening of confusion and has refused therapy services on multiple occasions. He was discharged from rehab services per the member's request. The member is medically stable and does not have any complex daily wound care, parenteral medications or required care for a feeding tube. As of 8/26/2021 the member did not require any skilled nursing or rehab services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of 8/26/2021. 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond August 26, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve promethazine 12.5mg tablets.

You asked the Plan to pre-approve the promethazine tablets. You say that this drug is necessary for use every 6 hours as need for nausea associated with chemotherapy. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B in this situation.

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 promethazine 12.5mg tablets.

Benefits for the promethazine tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on December 18, 2020.

You asked the Plan to waive the coinsurance for the Denosumab injection. You say that Medicare has always covered 100% of the injection. You say you need help. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 each in-network Medicare-covered Part B drug.

You have been asked to pay $241.44 which is 20% of the allowed amount for the Denosumab injection. The allowed amount is $1,207.20. ($1,207.20 x 20% = $241.44). The Denosumab injection falls within "Medicare Part B Prescription Drugs" 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 the denosumab injection provided on December 18, 2020.