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

We decided that the Plan does not have to waive the copayment for the outpatient surgery provided in an outpatient hospital facility on April 13, 2021.

You asked the Plan to waive the copayment for the outpatient surgery provided in an outpatient hospital facility. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgery provided in an outpatient hospital facility on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 Medicare-covered surgery or other services provided to you at a Tier 2 outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient surgery provided in an outpatient hospital facility on April 13, 2021. You have been asked to pay a $250 copayment for the outpatient surgery provided in an outpatient hospital facility. The outpatient surgery provided in an outpatient hospital facility falls within the Outpatient surgery 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 the outpatient surgery provided in an outpatient hospital facility on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing (codes 88305, 85097, 88360, 88341, 88313, and 88311) provided on June 14, 2021.

You asked the Plan to pay for lab tests. You say that the enrollee had multiple exams on this date and you are appealing to support this level of service. The Plan denied your request. The Plan says the denial of payment for these tests is correct, because the Plan previously paid these codes and there is no documentation to support additional testing so these charges are duplicates.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

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 lab tests. Our reviewer says that these codes do not meet the criteria for payment. Our reviewer found the medical and billing records submitted indicate that codes 88305, 85097, 88360, 88341, 88313, and 88311 were previously paid and there is no documentation submitted supporting additional testing with the use of these codes, therefore no additional payment is due.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing (codes 88305, 85097, 88360, 88341, 88313, and 88311) provided on June 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.

You asked the Plan to pre-approve Dupixent. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 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 Dupixent.

Benefits for Dupixent 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 10, 2021.

You asked the Plan to pay for the services provided. You say that there is no contractual agreement that the codes are included in the dialysis rate. The Plan denied your request. The Plan says the services were not billed as required by coding regulations.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable.

We looked at the file and the rules. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out of network second opinion.

You asked the Plan to pre-approve an out of network second opinion. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this provider is not in 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out of network second opinion.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 13, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. 

We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for colonoscopy services (45380) provided on July 2, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for colonoscopy services. You say that you believe this service should be covered. The Plan denied your request. The Plan says prior authorization was not obtained these services rendered by an OON provider.

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 colonoscopy services (45380) provided on July 2, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for foot orthotics.  You asked the Plan to pay for foot orthotics. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 10 outpatient physical therapy (PT) visits.  You asked the Plan to pre-approve 10 PT visits. You say that the additional visits are medically necessary. The Plan denied your request. The Plan says the additional PT visits are not medically necessary.  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 10 PT 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 found the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the patient's condition. The most recent therapy notes report the enrollee has overall demonstrated no significant change in symptoms with therapy; the biggest reported symptom is persistent right lower extremity pain. The reviewer found that the provided documentation indicates that the enrollee appears to have plateaued with therapy. The reviewer found that further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Therefore, the reviewer found that the requested 10 PT visits are not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 PT visits have not been met. Specifically, the file shows that the enrollee has plateaued with therapy. Therefore, we decided that the Plan does not have to pre-approve 10 outpatient physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G4 glucose monitor.

You asked the Plan to pre-approve glucose monitor. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because you have not tried and failed the Plan's preferred products of Freestyle Libre, Freestyle Libre II, Dexcom G5, and Dexcom G6.

The Plan must follow Medicare rules. Medicare rules say that a Plan may limit coverage to certain brand, items, and supplies. Your contract with the Plan says that the Plan covers Freestyle Libre, Freestyle Libre II, Dexcom G5, and Dexcom G6 therapeutic continuous glucose monitors. 

We looked at the file and Medicare rules. The requested Dexcom G4 is not one of the Plan's preferred products. Based on this information, we decided that Medicare rules for coverage of glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G4 glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for drainage of peritoneal abscess or localized peritonitis (49020) provided on May 11, 2020.

You asked the Plan to pay for drainage of peritoneal abscess or localized peritonitis. You say that the medical records provided support the claim as billed. The Plan denied your request. The Plan says an appropriate modifier was not billed to bypass the PTP edit.

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 code 49020 is a column II code to column I code 44143. 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 drainage of peritoneal abscess or localized peritonitis (49020) provided on May 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 17, 2020, through October 21, as billed.

You asked the Plan to pay for the acute inpatient hospital care as billed. You say that the documentation supports the principal diagnosis code billed, A41.9, defined as sepsis, unspecified organism The Plan denied your request. The Plan says the medical records do not support this billed diagnosis.

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. 

In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as sepsis, unspecified organism. 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 acute inpatient hospital care as billed. Our reviewer says that the principal diagnosis code billed with this inpatient hospital care stay is not supported in the medical documentation. Our physician reviewer found that the review indicates that the documentation supported an admission for pneumonia due to other gram-negative bacteria. The documentation was inconsistent regarding a diagnosis of sepsis. Even though sepsis is documented in the history and physical exam, progress notes, and discharge summary, supporting medical record documentation was not found within the record. Patient was a then, 86-year-old male with a past medical history of hypertension, coronary artery disease, and atrial fibrillation that presented with coughing, hemoptysis, and shortness of breath. While member presentation warranted consideration of sepsis as a diagnosis, there was no evidence of life-threatening organ dysfunction due to a dysregulated host response to infection. Sequential Organ Failure Assessment (SOFA) criteria as outlined in Sepsis 3 require the use of an arterial blood gas to calculate the P/F ratio. There were no arterial blood gas results found in the records that validate the patient having had a P/F ratio that was less than 400. There was insufficient evidence that use of peripheral oxygen saturation (SpO2) readings are reliable in calculating a patient's P/F ratio. Patient remained alert and oriented throughout admission. While platelets decreased there was not a rise in SOFA criteria. There was no evidence of significant physiologic instability. Therefore, the principal diagnosis code is not supported. 

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 the acute inpatient hospital care provided from October 17, 2020, through October 21, as billed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on June 21, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you were not aware this service would not be covered by the Plan. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 the office visit (99214) provided on June 21, 2021, 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 home infusion services (99601), and additional supplies, materials, and clinical staff time (99072) provided on December 29, 2020.  You asked the Plan to pay for the medical services. You say that you would like these services reprocessed based on the medical documentation provided. The Plan denied your request. The Plan says these 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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. The CPT Code Manual definition of code 99601 is home infusion or specialty drug administration per visit up to 2 hours.  We find that CPT code 99072 and 99601 are not eligible for payment as billed. Specifically, CPT code 99072 has a status indicator of "B" under the Physician Fee Schedule indicating that it is a bundled code. Payment for this service is always bundled into payment for other services not specified. Regarding CPT 99601, this code has a status code of "I" meaning that it is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion services (99601), and additional supplies, materials, and clinical staff time (99072) provided on December 29, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to be held harmless beyond any applicable cost share amounts for the acute inpatient hospital care provided from June 10, 2021, through June 12, 2021.

You asked the Plan to be held harmless beyond any applicable cost share amounts for acute inpatient hospital care. You say that the care you received was medically necessary. The Plan denied your request. The Plan says that this claim was billed with a bill type that indicates it as a nonpayment claim not eligible for payment.

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 acute inpatient hospital care by a contract provider. The hospital that the enrollee received the care was in-network. The file does not show that the plan provided notice that acute inpatient hospital care would not be covered. Under Medicare rules, this means acute inpatient hospital care is considered approved by the plan. Therefore, we decided that the Plan has to be held harmless beyond any applicable cost share amounts for the acute inpatient hospital care provided from June 10, 2021, through June 12, 2021.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee has not had a change in function that needs daily skilled therapy services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Zilretta.  You asked the Plan to pre-approve Zilretta. The Plan denied your request. The Plan says the enrollee has not tried and failed non-long lasting steroid injections.  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 Zilretta. Our physician reviewer found that the enrollee has unilateral primary osteoarthritis of the right knee. The Plan requires a trial of at least two of the following: Tylenol, Advil or similar drugs, and/or Tramadol. The Plan also requires that the enrollee has tried and failed or did not have a good enough response to a non-long-acting steroid injection of that knee. There is no documentation in the medical records that the enrollee has tried and failed the required medications. The review has determined that the requested use of Zilretta is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.