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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided
September 24, 2019 to October 23, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF
services. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of
coverage were not 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 pay for the SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily
basis and 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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for the skilled nursing facility (SNF) services provided September 24, 2019 to October 23,
2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) guidance rendered on October 23, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 77014 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 77014 and 77301. Code 77014 is a column II code with a modifier indicator of 1 when billed with column I code 77301. Code 77014 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) guidance rendered on October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean osteogenesis bone growth stimulator.You asked the Planto pre-approvethe stimulator. You say that this is medically necessary.The Plandenied your request. The Plansaysthe right humerus fracture happened on April 4, 2020.The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmedthat fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 stimulator. Our reviewer says that the requested stimulator is not medically reasonable or necessary. Our physician reviewer found the criteria is not met, as not enough time has passed since the last fracture.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 stimulator have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean osteogenesis bone growth stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from December 3, 2019 through December 5, 2019.
You asked the Plan to pay for inpatient mental health care. You say that the stay was medically necessary. 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 inpatient mental health care have not been met. Corrected claims along with all supporting documentation must be submitted to the Claims Department for review and consideration. Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from December 3, 2019 through December 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from September 26, 2018 to January 29, 2019.You asked the Plan to pay for the HIT services. You say that the enrollee has required these services related to the use of his pain pump. These services should be covered by the Plan.The Plan denied your request. The Plan says the code used to report these services is not valid for Medicare billing.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.CPT code S9328 has a status indicator of "I" in the Physician Fee Schedule, meaning this code is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met.Therefore, we decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from September 26, 2018 to January 29, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 11, 2019 to October 16, 2019.You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 to be 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 claim was billed with an incorrect type of bill code.Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 11, 2019 to October 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient mental health services provided to the enrollee from February 28, 2019 to March 7, 2019.You asked the Plan to pay forthe inpatient services. You say that the enrollee presented with disinhibited behaviors and confusion.The Plan denied your request. The Plan says the enrollee was not in imminent danger to self or others.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient services. Our physician reviewer found that active treatment was not taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. Based upon review the records, the enrollee did not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to herself or others, no auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. 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 inpatient services have not been met. Therefore, we decided that the Plan does not have to pay forthe inpatient mental health services provided to the enrollee from February 28, 2019 to March 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 4, 2019 through November 2, 2019.You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services.The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meetseverity 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 4, 2019 through November 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar sacral orthosis provided to the enrollee on December 19, 2019.
You asked the Plan to pay for the orthosis. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not support the diagnosis used on the submitted order, nor did the documentation indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate procedure code. In this case, the CPT Code Manual definition of HCPCS code L0650 is "Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf." We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the medical records provided do not support the diagnosis used on the claim for billed charges L0650. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar sacral orthosis provided to the enrollee on December 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral prescription drug Glyburide.
You asked the Plan to pre-approve oral prescription drug Glyburide. You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this is a self-administered drug and not a covered benefit.
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 oral prescription drug Glyburide.
Benefits for oral prescription drug Glyburide 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services provided on October 3, 2019 to December 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you were given the provider's information when you called the plan.The Plan denied your request. The Plan says the services were rendered by an out-of-network 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. The file shows that the Plan reviewed your call log history and found that you contacted them on November 8, 2019and were given a list of in-network chiropractors. The provider at issue was not given during that call. 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 chiropractic services provided on October 3, 2019 to December 20, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on December 6, 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 the services are not covered.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay forthe special pump services rendered on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveside guards for your wheelchair.You asked the Plan to pre-approveside guards. The Plan denied your request. The Plan says the requested item does not serve a medical purpose.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  We looked at the file and the rules. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approveside guards for your wheelchair.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were diagnosed with diabetes at a young age and you struggle to control it. You say that you were driving home when your sugar levels began to crash. You stopped at an intersection and several people came to check on you, one of whom called an ambulance. The EMT responders came and treated you, bringing your sugar levels back to normal. You say that you were told there would be no charge because there was no need for transport. You say that the Plan should cover the ambulance services because you were in dire need of assistance even though you did not need to go to the hospital. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 22, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGel-One.You asked the Plan to pre-approveGel-One. You say that the requested Gel-One is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc AND Monovisc first.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 Gel-One. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with knee pain and a diagnosis of left knee osteoarthritis, confirmed by x-rays. The enrollee has failed conservative treatment. She had a Monovisc injection in the left knee on 04/10/2018 which by report from the provided medical records did provide some pain relief for a few months; Gel-One injection is now requested. There is documentation of prior use of Monovisc with some improvement in symptoms for several months. The provided medical records do not indicate that Orthovisc has been tried or that it would likely be less effective and/or 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 Gel-One have not been met.Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on September 19 to September 20, 2019.You asked the Plan to pay for the critical care services. You say that the services were medically necessary.The Plan denied your request. The Plan says the records do not support the services billed.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 99291 is critical care visit of 30-74 minutes.We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show how much time was spent on the critical care services. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met.Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on September 19 to September 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the
enrollee is with prior multiple hemorrhagic strokes and seizure disorder who presents secondary to recurring
seizures. The enrollee admitted to acute care for septic shock and urinary tract infection for which he required
intubation.
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not
provide clinical services that are materially different than those of short term acute care hospitals. In this case,
ongoing care needs include respiratory support including oxygen supplementation and aspiration precautions,
intravenous antibiotics, seizure precautions, surveillance laboratory studies, and therapy services. 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. There are no required medical services
identified that are available at the LTACH, that are not available at the current health care setting being offered
by the health plan. Consequently, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxais medically necessary.The Plan denied your request. The Plan says the requested Euflexxa does not meet criteria.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 Euflexxa. Our reviewer says that the requested Euflexxa does not meet criteria. Our physician reviewer found the enrollee is with bilateral knee pain due to primary osteoarthritis of both knees. The provider is requesting bilateral intra-articular knee joint injections with Euflexxa. Based on the LCD, the member must fail at least 3 months of conservative therapy including, physical therapy or home exercise and medications such as Tylenol or nonsteroidal anti-inflammatory drugs, prior to consideration for this viscosupplemental treatment/injection. The member's records do not show that the member has tried other therapy to help with the pain. The documents do not meet the criteria for conservative treatment. In addition, the member must fail to respond to knee joint aspiration, which is also not documented in the records. The review has determined that the enrollee does not meet the criteria for the requested (J7323) Euflexxa intra-articular injections of both knees. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approve Euflexxa.