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

We decided that the Plan does not have to pre-approve Denosumab.

You asked the Plan to pre-approve Denosumab. You say that Denosumab was superior to Zoledronic Acid for the enrollee. The Plan denied your request. The Plan says the requested service does not meet medical necessity criteria as the documentation received did not advise of at least one preferred product (Pamidronate or Zoledronic Acid) being tried in the past 90 days, or that at least one preferred product has been ineffective, not tolerated, or contraindicated.

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 Denosumab. Our reviewer says that Denosumab is not medically reasonable and necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative, Pamidronate or Zoledronic Acid. Our reviewer found that the record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred step one alternatives. Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Denosumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Denosumab.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on May 10, 2021.  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 not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on October 5, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for dental services. You say that you would like to pay a 50% coinsurance. The Plan denied your request. The Plan says the rendering dentist is 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 had network providers available who could have provided 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 dental services provided on October 5, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from September 9, 2021, to September 12, 2021.  You asked the Plan to waive the copayment for inpatient hospital care. You say that you thought that your services would be fully covered due to being a multi-donor. 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 $300 copayment for days 1-6 for inpatient hospital care.   The medical records show that you had inpatient hospital care from September 9, 2021, to September 12, 2021. Therefore, you are responsible to pay a $300 copayment for days 1-3 (September 9, 2021, to September 11, 2021). The total amount you owe is: $300 (copayment) x 3 (inpatient days) = $900.    You have been asked to pay the total copayment amount of $900 for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital 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 to waive the copayment for inpatient hospital care provided from September 9, 2021, to September 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection of a therapeutic or diagnostic substance (62320) provided on September 20, 2021.  You asked the Plan to pay for the injection of a therapeutic or diagnostic substance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this provider has not submitted medical records to support the medical necessity of this service.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection of a therapeutic or diagnostic substance have not been met. Specifically, the documentation submitted does not include any medical records. There is insufficient information to determine if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the injection of a therapeutic or diagnostic substance (62320) provided on September 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient hospital services (CPT code G0378) provided from August 13, 2021, through August 26, 2021.  You asked the Plan to pay for the outpatient hospital services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as 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 G04378 is hospital observation service, per hour.  We find that CPT code G0378 is not supported in the medical record. Specifically, it is not appropriate to bill more than one line of observational services per claim.  In this case multiple lines of CPT code G0378 have been billed. This does not meet Medicare guidelines for billing or reimbursement consideration. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services (CPT code G0378) provided from August 13, 2021, through August 26, 2021.
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 does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had a prolonged hospital course, including acute kidney injury, and although is she improving, still requires ongoing acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study (93971) rendered on August 31, 2021.  You asked the Plan to waive the copayment for a duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study. You say that this should have been covered. The Plan denied your request. The Plan says you were charged the correct copayment 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 $160 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). The contract with the Plan also says that the diagnostic radiology services require specialized equipment beyond standard x-ray equipment and must be performed by specially trained or certified personnel, and an example includes, but is not limited to, ultrasounds.   You have been asked to pay $114.18, which is less than the $160 copayment for a duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study. A duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The record shows that this service was covered by the Plan, however, there is a cost sharing amount you are responsible for. 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 copayment for a duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study (93971) rendered on August 31, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custodial care services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the service is not a covered benefit.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. We find that the services at issue in this case are considered custodial in nature. Custodial care is not covered by Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve custodial care services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services rendered on July 7, 2021.  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 99291 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.  We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of a critical care visit of 30-74 minutes for the billed date of service. 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 for the critical care services rendered on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for triamcinolone acetonide injections (J3301, 64405) rendered from December 29, 2020, to March 30, 2021.  You asked the Plan to waive the copayment for triamcinolone acetonide injections. You say that you had two injections each time you saw the provider and no surgery was required or performed but that's what was coded on y our bills. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities.    You have been asked to pay a $250 copayment for each triamcinolone acetonide injection, which totals $500 ($250 copayment x 2 injections = $500). Triamcinolone acetonide injections falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayment for triamcinolone acetonide injections (J3301, 64405) rendered from December 29, 2020, to March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital care provided from April 11, 2021, through April 17, 2021.  You asked the Plan to pay for inpatient hospital care. You say that you submitted documentation to support appeal of Diagnosis Related Group code. The Plan denied your request. The Plan says the determination to remove secondary diagnosis code A41.9. (Sepsis, organism unspecified) is upheld.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    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 inpatient hospital care. Our physician reviewer found the reviewed documentation indicates that the patient presented to the facility with the chief complaint of obstructive uropathy with a urinary tract infection. Initial vital signs included the pulse was over 100, respiratory rate was 22, temp was < 99 and B/P was 102/61 and 116/74 with saturations of 94%. The patient was described in the emergency department as in no acute distress, with normal cardiovascular and pulmonary assessments beyond the rib pain, capillary refill of < 2 seconds and a mentation exam that stated the patient was alert and oriented x 3. ED provider notes did not clearly state the patient was in a state of sepsis upon presentation. The history and physical first stated the diagnosis of sepsis, however the patient was also described to have a heart rate that had "resolved" with fluids, and mean arterial pressures were > 70 mmHg with saturations of 100% and lactic acid of 1.1 mmol/L. The diagnostic information indicates the patient maintained daily laboratory results of creatinine, platelet, and total bilirubin level within normal limits. Further provider documentation during the encounter indicated the patient's mental status remained intact with GCS of 15, and the patient was without provider support of acute respiratory abnormality during the encounter. Although it is acknowledged the patient had support via diagnostic data and provider documentation of a localized infection of the urinary tract with the elevation of HR and fever, the patient was without diagnostic signs or provider documentation of organ dysfunction in the medical record provided. There was no documentation of sepsis. The review has determined that A41.9. (Sepsis, organism unspecified) was not supported in the medical record.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from April 11, 2021, through April 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent hospital care (99233) provided May 29, 2021.  You asked the Plan to pay for the hospital care. You say that your physician provided medically necessary services to the enrollee in good faith and the rendered services meet professionally recognized standards of healthcare. The Plan denied your request. The Plan says the primary payer's explanation of benefits has not been received.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another payer as the primary payer. As the secondary insurer, the Plan cannot be held responsible for the hospital care until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99233) provided May 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (64490, 64491, 64492) provided on August 20, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are bundled.  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, we have confirmed that codes 64490, 64491, and 64492, are column II codes to column I code 11900. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (64490, 64491, 64492) provided on August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and incomplete root canal (D3332) provided on October 15, 2021.  You asked the Plan to pay for the dental services. You say that you had a toothache. You say that the provider was not able to save your tooth. You say that you were referred to an oral surgeon for an extraction. You also say that the services should be covered. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per year. The Plan says the frequency limit has been exceeded. The Plan also says that incomplete root canal is not listed as a covered service.  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 and limited oral evaluation is covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on October 13, 2021. Additionally, incomplete root canal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), and incomplete root canal (D3332) provided on October 15, 2021.