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

We decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service coded 99053 provided on May 19, 2021.
You asked the Plan to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service.
We find that CPT code 99053 is not supported in the medical record. Specifically, this code has a status code of "B". A status code of B means that this code is bundled into procedure codes 99285 and 93010 and are not separately payable. Based on this information, we decided that Medicare rules for coverage of the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service have not been met. Therefore, we decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service coded 99053 provided on May 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple venous procedures (intravascular ultrasound [IVUS], angioplasty, stenting, sedation) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered to be reasonable and necessary when there is documentation of certain conditions.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the health plan's position that requests for invasive procedures be supported by evidence on non-invasive testing is reasonable. The documentation does not support the medical necessity of the procedures requested. The physical examination documents a lateral ulcer near the ankle with trace pedal edema. It appears that the plan for IVUS and venography was made prior to obtaining any of the non-invasive studies that were ordered.

The enrollee has a diagnosis of peripheral vascular disease. Arterial ultrasound of the leg was requested but the results have not been provided. It is unclear why waveform analysis and toe pressures are not available for the left leg. There are no findings on the venous duplex to suggest proximal disease. The documentation does not describe a concerted effort at conservative treatment. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve multiple venous procedures (intravascular ultrasound [IVUS], angioplasty, stenting, sedation) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on August 12, 2020, to August 21, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says that medical records show that the enrollee's condition meets the medical necessity criteria for the observation level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided on August 12, 2020, to August 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued 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 there are no noted daily skilled complex nursing or therapy needs which would meet the guidelines for continued SNF 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 your condition does not meet Medicare criteria for continued 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 continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for your full recovery. The Plan denied your request. The Plan says transfer to an LTACH is not medically necessary. You are receiving appropriate care in the current acute setting and are not stable for transfer. You need to remain in your current hospital until your full course of care is completed.
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 in this case that you were admitted with acute hypoxic respiratory failure due to COVID-19 pneumonia. The record indicates you are still acutely ill. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested transfer 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SpaceOAR procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare criteria states that radiation therapy must be equal to or more than 76GY.

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found SpaceOAR is a hydrogel spacer inserted between the rectum and prostate in order to reduce the dose exposure of the rectum- and thus rectal toxicity - in men undergoing radiation for prostate cancer. The LCD criteria are not met, as the criteria are explicit in which risks groups are covered and also the need to use SpaceOAR when other techniques would be insufficient. The enrollee is being offered Calypso, which is a real-time tracking system, and there is no plausible reason as to why this alone (i.e. without the SpaceOAR) would be insufficient in this 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the SpaceOAR procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected in your case. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 13, 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 claim was not processed by the primary insurance. 
 
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 not received 
an Explanation of Benefits (EOB) from the primary insurer for this claim. As the secondary insurer, the Plan 
cannot be held responsible for these services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 13, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the hearing aids provided on January 19, 2021.

You asked the Plan to pay more for the hearing aids. You say that you were to receive $700 and are now being
told you would only receive $350. You say that you were denied the 50% reimbursement. The Plan denied
your request. The Plan says the claim processed correctly.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan only pays
$350 for each hearing aid only when they are received from an in-network provider.

We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Specifically, the Plan is only obligated to reimburse 50% of the
allowed amount for each hearing aid from an out-of-network provider. The allowed amount for each hearing
aid is $350 and 50% of each hearing aid is $175. ($175/hearing aid x 2 hearing aids = $350). This means that a
total reimbursement of $350 is correct. Therefore, we decided that the Plan does not have to pay more for the
hearing aids provided on January 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care provided from November 20, 2020, to November 25, 2020.
You asked the Plan to pay an additional amount for the inpatient care. You say that the secondary diagnosis of acute hypoxic respiratory failure is clearly documented, clinically valid and treated. You say that this diagnosis helps to capture the true severity of the enrollee's illness and acuity and therefore should be coded. The Plan denied your request. The Plan says while acute hypoxemic respiratory failure was documented in the record, other provider documentation was incomplete regarding this condition.
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 secondary diagnosis code, J96.01, defined as acute respiratory failure with hypoxia. 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 an additional amount for the inpatient care. Our reviewer says that the diagnosis of acute respiratory failure with hypoxia is not supported. Our physician reviewer found the provided documentation indicates that the enrollee was hypoxic to 85% on room air and short of breath on arrival in the emergency department. The reviewer found that the enrollee was treated, and hypoxia and symptoms improved. The reviewer found that the documentation shows the enrollee later had nonlabored breathing but wheezes. Repeat testing off oxygen supplementation showed 95% at rest. The reviewer found that the enrollee was diagnosed with pneumonia and other pulmonary eosinophilia. The reviewer found that the documentation of billing of acute hypoxic respiratory failure, International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) was included in the records. The reviewer also found that based on the records at the time of admission, the enrollee was recovering sufficiently that they did not require oxygen supplementation at rest and would not meet criteria for the diagnosis of acute hypoxic respiratory failure for hospital treatment. 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. Specifically, the file does not support the billing of the secondary diagnosis code of acute respiratory failure with hypoxia. Therefore, we decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care provided from November 20, 2020, to November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3310) provided on May 26, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the endodontic therapy. You say that your book says that you can see any provider, and you did not receive a new book or letter informing you of the change. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective December 10, 2015, to December 10, 2021.
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, the requested items or services are not covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3310) provided on May 26, 2021 by a Medicare opt out provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90832) provided February 3, 2021 to February 17, 2021.

You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider is not eligible for Medicare payment.

The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.

We looked at the file and Medicare rules. The provider was not eligible for Medicare payment at the time services were rendered. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90832) provided February 3, 2021 to February 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neurophysiology services (95938, 95939, 95940) provided to the enrollee on November 2, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says billing these services by another provider represents a duplication of effort and an overlap of services.

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 the denied codes is: 

CPT 95938: 

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs CPT 95939:

Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs 

CPT 95940:

Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found payment for the denied codes was included in the facility/hospital reimbursement; therefore, no additional reimbursement is allowed. In this case, the services submitted by the provider were already billed and reimbursed by the health plan to the hospital, resulting in duplicate charges. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for neurophysiology services (95938, 95939, 95940) provided to the enrollee on November 2, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Epogen.

You asked the Plan to pre-approve Epogen. You say that the enrollee needs this drug due to his condition. The
Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan
requires a trial of Retacrit before it will approve Epogen.

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 Epogen. Our reviewer says that the
enrollee does not meet the Medicare criteria for a step therapy exception for Epogen. Our physician reviewer
found the enrollee has not tried and failed the Plan's preferred drug of Retacrit. The documentation does not
show that this drug would likely be less effective and/or 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 Epogen have not been met. Therefore, we decided that the Plan does not have to
pre-approve use of Epogen.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 11, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that authorizations are not required for office visits. The Plan denied your request. The Plan says prior authorization was not requested as required.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on June 11, 2021 by an out-of-network provider.