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

We decided that the Plan does not have to pay for the home visit services coded 99348 provided on July 17, 2019.
You asked the Plan to pay for the home visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided were billed incorrectly.
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 99348 is home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low 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 presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99348 is not supported in the medical record. Specifically, the submitted code does not appropriately reflect the services provided by the LVN. A home visit cannot be billed by a physician unless the physician was actually present in the enrollee's home. Based on this information, we decided that Medicare rules for coverage of the home visit services have not been met. Therefore, we decided that the Plan does not have to pay for the home visit services coded 99348 provided on July 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient rehabilitation services provided on August 2, 2019 to August 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the inpatient services. You say that This admission was medically necessary. Your surgeon recommended that a short stay in rehab would assist in obtaining outcome after surgery to repair a torn left quadriceps muscle. The Plan denied your request. The Plan says non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 inpatient rehabilitation services provided on August 2, 2019 to August 8, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 16, 2020 by an out of network (OON) provider.You asked the Plan to pay foroutpatient surgery. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has topay 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 forthe medical services provided on January 16, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on November 27, 2019.You asked the Plan to pay forgenetic test. You say that this test was medically necessary.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because progress notes were not obtained from the ordering physician to determine the clinical utility of this testing.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.The enrollee was referred for genetic test by an in-network provider. The file does not show that the plan provided notice that genetic test would not be covered. Under Medicare rules, this means genetic test is considered approved by the plan.Therefore, we decided that the Plan has to pay forgenetic testing provided on November 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGabapentin 600mg tablet.You asked the Plan to pre-approveGabapentin 600mg tablet. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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-approveGabapentin 600mg tablet.Benefits for Gabapentin 600mg tabletmay 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 waive the copayment foran office visit provided on December 31, 2019.You asked the Plan to waive the copayment foran office visit. You say that you were not informed that the physician was a specialist and should only owe a $15 copayment.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 $45 copayment for out-of-network primary care provider visits. You received an office visit with an out-of-network provider on December 31, 2019. Therefore, you are responsible to pay the $45 copayment. You have been asked to pay a $45 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 paywhen you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran office visit provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora home podiatry visit (99348, 11721) provided on October 2, 2019 by an out of network (OON) provider.You asked the Plan to pay fora home podiatry visit. You say that these services have been covered in the past.The Plan denied your request. The Plan says these 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 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 fora home podiatry visit (99348, 11721) provided on October 2, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diabetic shoes and ankle orthoses provided on October 3, 2019.You asked the Plan to pay forthe diabetic shoes and ankle orthoses. You say that the Plan should pay this claim.The Plan denied your request. The Plan says thereis no valid physician order.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 for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. The physician order is not signed and dated.Therefore, we decided that the Plan does not have to pay forthe diabetic shoes and ankle orthoses provided on October 3, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered on November 18, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 20680 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 20680 is removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate).We find that CPT code 20680 is not supported in the medical record. Specifically, the operative report does not include documentation of three units of removal of a deep implant. 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 forthe surgical services rendered on November 18, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 30, 2019 to December 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the Plan failed to approve or respond  to your request, and you proceeded to get the enrollee the treatments.The Plan denied your request. The Plan says the provider is not in network, and there is no authorization on file.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 OON services. Therefore, we decided that the Plan does not have to pay forthe medical services provided on September 30, 2019 to December 4, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve2 injections of OnabotulinumtoxinA (Botox), 200 units each.You asked the Plan to pre-approvethe Botox injections. You say that the enrollee has Parkinson's disease. You say it is complicated by the presence of focal right foot dystonia causing inversion of the foot, gait disturbance and risk of falls. You also say that the Botulinum Toxin is a mainstay treatment of focal dystoniasuch as focal foot dystonia, including in the setting of Parkinson's disease.The Plan denied your request. The Plan says that the Botox is not medically necessary. The Plan says that the information provided does not how that the policy requirements have been met. The Plan also says that the use in treatment of right foot dystonia is not supported by the Food and Drug Administration (FDA) or nationally recognized compendia.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Botox injections. Our reviewer says that the service is medically necessary. Our physician reviewer found that the enrollee is a female with a history of Crohn's disease and Parkinson's disease complicated by the presence of focal right foot dystonia causing inversion of the foot, gait disturbance, and an increased risk for falls. She has not responded to oral medication adjustments including a change in her dopaminergic therapies. The enrollee is not a candidate for the use of anticholinergic medications due to the significant cognitive side effect profile and possible worsening of her Crohn's disease.Botulinum toxin injections are used to treat various focal muscle spastic disorders and excessive muscle contractions such as dystonia, spasms, twitches, etc. They produce a presynaptic neuromuscular blockade by preventing the release of acetylcholine from the nerve endings. The resulting chemical-denervation of muscle produces local paresis or paralysis and allows individual muscles to be weakened selectively. According to DrugDex, a Medicare-approved compendium: "OnabotulinumtoxinA is indicated in adults to decrease the severity of increased muscle tone in ankle and toe flexors." The reviewerhas determined that the documentation supports that the Botox is medically reasonable and necessary for the enrollee's diagnosis. The documentation supports that the Botox is safe and effective for the enrollee.We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Botox injections have been met.Therefore, we decided that the Plan has to pre-approve2 injections of OnabotulinumtoxinA (Botox), 200 units each.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cervical/vaginal screening provided on May 16, 2019.You asked the Plan to pay forthe screening. The Plandenied your request. The Plan says this is covered once every two years.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 $0 copayment for a cervical and vaginal cancer screening once every 24 months. Review of the file shows that the enrollee was provided a cancer screening on May 16, 2019. The records also show that the enrollee was provided a covered screening on May 2, 2018. The requested screening was provided less than two years after the covered screening. This exceeds the benefit limit.Therefore, we decided that the Plan does not have to pay forthe cervical/vaginal screening provided on May 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump (99190) provided on January 31, 2020.You asked the Plan to pay forthe pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to stay in the operating room during the length of the procedure.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital forservices furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump (99190) provided on January 31,2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure (E0652).You asked the Plan to pre-approvea segmental pneumatic appliance for use with pneumatic compressor, full leg and pneumatic compressor. You say that the items are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that the trial of conservative therapy must be documented in the beneficiary's medical record before prescribing any type of pneumatic compression device (E0650, E0651, E0652).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 a segmental pneumatic appliance for use with pneumatic compressor, full leg and pneumatic compressor. Our reviewer says that the items are not medically necessary. Our physician reviewer found there are no clinical notes besides the physical therapy (PT) notes dating a week before the prescription. More importantly the physician's prescription is not substantiated with a physical exam and assessment of the edema or extension to the trunk and skin condition to say that she has hyperkeratosis with hyperplasia and hyperpigmentation, Papillomatosis cutis, elephantiasis, or skin breakdown with persisting lymphorrhea. The PT notes lack sequential measurements of the legs to assess the swelling either progress or deterioration except subjective complaints. Conservative measures have failed. Trial with basic lymphedema pump caused worsening of the swelling and the trunk. There was no evidence of a four-week trial of the basic lymphedema pump with close medical supervision within the medical records. In the absence of appropriate interventions and documentation, the Segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667) and Pneumatic compressor, segmental home model with calibrated gradient pressure (E0652) are not medically necessary.We looked at this physician'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a segmental pneumatic appliance for use with pneumatic compressor, full leg and pneumatic compressor have not been met.Therefore, we decidedthat the Plan does not have to pre-approvea segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe life vest provided on February 3, 2020.You asked the Plan to waive the coinsurance forthe life vest. You say that you would not have accepted this item if you knew the cost associated with it.The Plan denied your request. The Plan says that you were billed 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 a 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the life vest. The life vest falls within the durable medical equipment (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 forthe life vest provided on February 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean interspinous and/or interlaminar device.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that this device is helpful for treatment of your health problem.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 pre-approve the device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the device remains experimental. More research is needed to show safety and effcacy.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 device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean interspinous and/or interlaminar device.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe injection of sclerosant (36471) provided on January 15, 2020.You asked the Plan to pay forthe injection of sclerosant. You say that you would like reconsideration because you were told this service would be covered.The Plan denied your request. The Plan says that it was previously communicated to you that this service would not be covered.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 gatherand forward to us information regarding their decision to deny your request. The Plan has failed to forward medical records regarding the service at issue to verify its medical necessity.Therefore, we decided that the Plan has to pay forthe injection of sclerosant (36471) provided on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 12, 2019.You asked the Plan to pay forthe 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 12, 2019