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

We decided that the Plan does not have to pay for train of four testing (95999) provided on February 1, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment for train of four testing is included in payment for other services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on February 1, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvea brow lift (67999).You asked the Plan to pre-approvea brow lift (67999). You say that the requested brow lift is medically necessary.The Plan denied your request. The Plan says that the requested brow lift is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a brow lift (67999). Our reviewer says that the requested brow lift is medically necessary. Our physician reviewer found the enrollee is with evidence of bilateral upper eyelid dermatochalasis and significant bilateral brow ptosis that is well-documented to have caused visual impairment. Photographs were difficult to fully analyze but appeared to support significant brow ptosis below the supra-orbital rim, as documented in the medical records. Bilateral upper blepharoplasty had been approved but not brow lift. Based on the documentation provided, the enrollee has evidence of visual impairment as the direct result of the upper eyelid skin excess and brow ptosis. This is supported by the medical documentation and review of the photographs. Only addressing the eyelid skin may not provide complete resolution of her visual impairment. Therefore, both correction of the upper eyelid skin excess and brow ptosis, specifically satisfy the above Medicare medically necessary criteria.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a brow lift (67999) have been met.Therefore, we decided that the Plan has to pre-approvea brow lift (67999).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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance provided on October 14, 2019.You asked the Plan to pay forthe periodontal maintenance. You say that periodontal maintenance is a cleaning and exam which is clearly identified as a covered benefit. You also say that there is no reason that this claim should have been denied.The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periodontal maintenance provided on October 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 24, 2019 by an out of network (OON) provider.
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 were rendered by a non-participating provider without prior authorization.
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 for the medical services provided on October 24, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on July 3, 2019.You asked the Plan to waive the copayment for the ED visit. You say that you were less than a month post-operative. You say that you shouldn't have to pay the bill.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 $120 for each Medicare-covered emergency room visit.You have been asked to pay $115.71, which is less than the standard $120 copayment for the ED visit. The ED visit falls within the "Emergency 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 towaive the copayment forthe ED visit provided on July 3, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the head or brain, CT angiography of the head, and CT angiography of the neck provided on February 28, 2019.
You asked the Plan to pay for the CT scans. You say that the enrollee did not enroll in hospice care until 16:35 on February 28, 2019. You also say that these services were provided at 9:40 am. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the CT of the head or brain, CT angiography of the head, and CT angiography of the neck provided on February 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET/CT scan.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records did not show that other tests were done first, and how this test will change treatment.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found first, there is no PET/CT report is in the provided records however if one assumes the intake summary is correct and the splenic lesion was noted to have been not hypermetabolic the fact the yearly surveillance ultrasound, CT and MRI scans show no change in size over the course of 4 years and there is no other abnormal imaging or clinical finding to suggest lymphoma there is no valid medical necessity to pursue another PET/CT in light of the stability of the lesion size over 4 years, lack of malignant diagnosis elsewhere and history of no hypermetabolic activity in the lesion on prior PET. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET/CT scan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha sureclick for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrollee has intolerance to statin therapy.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-approveRepatha sureclick for the enrollee.Benefits for this drug may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for triamcinolone acetonideand dexamethasone (J3310, J1100 and 96372) provided on September 12, 2019.You asked the Plan to pay for the corticosteroid injections. You say that this service was medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says this service is experimental or not an accepted use of the drug.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 pay for the corticosteroid injections. Our reviewer says that injected corticosteroids are not FDA-approved or supported by available high-quality evidence to support treating allergic rhinitis, acute maxillary sinusitis, or acute pharyngitis Our physician reviewer found this injection is not the safe for the member and would not likely be significantly more effective than the oral corticosteroids being used alone.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 corticosteroid injections have not been met. Therefore, we decided that the Plan does not have to pay for triamcinolone acetonide and dexamethasone (J3310, J1100 and 96372) provided on September 12, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ER visit on May 20, 2019.You asked the Plan to waive the copayment foran ER visit. You say that you disagree with the charges because the enrollee was admitted to the hospital.The Plan denied your request. The Plansays 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $110 copayment for emergency care. The enrollee had an ER visit on May 20, 2019. The record shows that the enrollee was admitted on May 22, 2019, which is more than 24 hours from this ER visit. Therefore, the enrollee is responsible to pay the $110 copayment. The enrollee has been asked to pay a $110 copayment for an ER visit. An ER visit falls within the emergency care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran ER visit provided on May 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve admission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansayscare can be received in another setting.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 your medical condition was stable. There were no wound care needs. You did not require medical oversight of your condition at an acute hospital level of care. You were ambulating greater than household distances as well as on stairs and did not require an intensive rehabilitation therapy program. There would be no expected need to modify your treatment to maximize your capacity to benefit from rehabilitation. Physician supervision at an acute rehabilitation level of care was not required. Your condition can be be appropriately treated by progressing your mobility with the physical therapy treatments being provided including instruction in pulmonary rehabilitation techniques. You would not be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. Your care can be provided at a lower level of care including at the SNF level.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlaminectomy services (CPT 63048) provided to the enrollee on August 27, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthere is an invalid/missing modifier.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 CodeManual definition of code 63048 is "Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)), single vertebral segment; eachadditionalsegment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)."We find that CPT code 63048 is not supported in the medical record. Specifically, this code was billed with modifier 51, which is invalid in this case. 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 pay forlaminectomy services (CPT 63048) provided to the enrollee on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on July 1, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.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 canprovide 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 forthe medical services provided to the enrollee by an out-of-network provider on July 1, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance forthe professional services for immunotherapy provided from September 3, 2019 through September 30, 2019.You asked the Planto waive the coinsurance forthe professional services for immunotherapy. You say that your responsibility increased but the fee charged has not changed.The Plan denied your request. The Plan says that the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees pay $0 for the administration of allergy shots and serum. The Plan says you must pay 20% coinsurance for the professional services for immunotherapy. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the professional services for immunotherapy.Therefore, we decided that the Plan has to waive the coinsurance forthe professional services for immunotherapy provided from September 3, 2019 through September 30, 2019.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 thePlan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 30, 2019.You asked the Plan to pay forthe assembly and operation of pump with oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment of this service is included in the DRG payment.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided thatthe Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 1, 2019 to October 15, 2019.You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim form does not have the appropriate home health data to process and pay the claim.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services tobe covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim is not includea valid Type of Bill.. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 1, 2019 to October 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF currently. You are noted to have rising creatinine and are not medically stable yet for transfer to a rehabilitation program. You do not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services(or a combination of these services) on a "daily basis" in a SNF. As a practical matter you do not require the necessary services on an inpatient basis, in a SNF setting 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.