Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a prolonged service in the inpatient or observation setting (99356) provided on April 30, 2019.
You asked the Plan to pay for the prolonged service. You say that per CMS, 99356 is payable when billed with CPT code 99309. The Plan denied your request. The Plan says because the average time for the nursing facility care visit code is 35 minutes, the prolonged service code (30-74 minutes above the time given for the base code) is not warranted with this code.
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 99356 is prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service). 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 prolonged service. Our reviewer says that CPT code 99356 does not meet criteria for billing or reimbursement consideration. Our reviewer found because the more appropriate code is based on the base time of 35 minutes, it is inappropriate to submit Current Procedural Terminology (CPT) code 99356. The additional minutes above the appropriate base code does not equal 30-74 minutes.
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 prolonged service have not been met. Therefore, we decided that the Plan does not have to pay for a prolonged service in the inpatient or observation setting (99356) provided on April 30, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve urology consultation to be provided by tertiary level of care provider.
You asked the Plan to pre-approve tertiary urology consultation. You say that the Plan's recommended urologists do not perform the procedure which you need. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because you can be treated at a lower level of care. The Plan also says that if, after an evaluation with a non-tertiary provider, the non-tertiary provider feels that tertiary level of care is necessary, then tertiary care can be approved.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. 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 tertiary urology consultation. Our reviewer says that you meet the Medicare criteria for urology treatment at the requested tertiary level of care provider. Our physician reviewer found repeat retroperitoneal lymph node dissection (RPLND) for the treatment of your condition is an uncommonly performed procedure and is usually performed at tertiary centers that have unique experience with this procedure. The surgeon must be prepared to perform additional surgical procedures with resection of adjacent vascular and visceral structures in up to 50% of cases. It is highly unlikely that community-level providers would have the expertise for this procedure. Therefore, the best care for you would be at the requested tertiary care center with special expertise in repeat RPLND surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tertiary urology consultation have been met. Therefore, we decided that the Plan has to pre-approve urology consultation to be provided by tertiary level of care provider.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inversion/eversion correction device (A9285), for the enrollee.
You asked the Plan to pre-approve the inversion/eversion correction device. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 inversion/eversion correction device have not been met. This item is not covered under Medicare or the Health Plan. The rules say that an inversion/eversion correction device (A9285) is denied as non-covered (no Medicare benefit), because it does not act as a brace; that is, it does not support a weak or deformed body member or restrict or eliminate motion in a diseased or injured part of the body. Therefore, we decided that the Plan does not have to pre-approve inversion/eversion correction device (A9285), for the enrollee.
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 member will have an unplanned readmission if admitted to a lower level of care. The Plan denied your request. The Plan says the necessary services may be provided at a lower level of care.
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 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. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia for dental extractions.
You asked the Plan to pre-approve the anesthesia. You say that this is medically necessary. The Plan denied your request. The Plan says dental anesthesia is never covered under the medical benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve anesthesia for dental extractions.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for surgery services (15734, 49566 and 49568) provided on April 10, 2019.
You asked the Plan to pay for the surgery services. You say that these services are not included in the global surgery package for date of service, April 5, 2019. The Plan denied your request. The Plan says that the service was not billed with an appropriate modifier and falls within the 90-day global surgery package of another procedure.
The Plan must follow Medicare rules. Medicare rules say that services that are not considered part of the global surgery package include services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care. We find that the surgery services provided on April 10, 2019 are supported in the record. Specifically, these services are not included in the global surgery period for 43840 because they have been rendered by a separate provider and there is no indication that the original surgeon transferred post-operative care to the provider. The surgery provided by the provider begins its own separate global period and does not require a modifier to indicate that this service was unrelated to the surgery provided by a different provider on April 2, 2019. Based on this information, we decided that Medicare rules for coverage of the surgery services have been met. Therefore, we decided that the Plan has to pay for surgery services (15734, 49566 and 49568) provided on April 10, 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 the Plan does not have to pay for behavioral health services provided on January 16, 2019.
You asked the Plan to pay for the behavioral health services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 behavioral health services provided on January 16, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.

You asked the Plan to pre-approve Procrit. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for Procrit is correct, because the Plan requires a trial of Retacrit before it will approve Procrit.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Procrit. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Procrit. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of Retacrit. The documentation does not support that Retacrit would likely be less effective and/or would likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on September 23, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on September 23, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve these services. You say that the scan will be beneficial to find your status as a previous smoker. The Plan denied your request. The Plan says you do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that LDCT for lung cancer screening is covered when specific criteria are met. We looked at the file and Medicare rules. The file shows that you quit smoking more than 15 years ago. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 9, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 did not pre-approve the service 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 laboratory services provided on September 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 1, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 laboratory services provided on October 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 7, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 10, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2810, L2397) provided to the enrollee on May 15, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says there is no commensurate note in the medical record on or around that date as to why the brace was being ordered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. There is no information from a face to face encounter to support the validity of the physician order for this device, so it's necessity cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2810, L2397) provided to the enrollee on May 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 6, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 9 additional physical therapy visits.
You asked the Plan to pre-approve the 9 additional physical therapy visits. You say that you have gotten worse in the last and stuck in your wheelchair. You say you need additional physical therapy in order to get back to walking. The Plan denied your request. The Plan says the medical records did not provide sufficient documentation of medical necessity.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 9 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer says the requested therapy of 9 more sessions is not generally accepted as specific and effective therapy for the enrollee's condition. Our physician reviewer found the enrollee's current function does not require the unique skills of a professional therapist to safely and effectively provide treatment. Our physician reviewer also found the services do not need to be only performed by a therapist, or under the supervision of a therapist, and the services are not part of a maintenance program.
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 9 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the 9 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on August 15, 2019 by the out-of-network provider.
You asked the Plan to pay for outpatient lab work. You say that you do not see the member. You say that your services are an extension of the initial visit. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 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 outpatient lab work provided on August 15, 2019 by the out-of-network provider.