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

We decided that the Plan does not have to pay for procedure code 50561-59-51.

You asked the Plan to pay for procedure code 50561-59-51. You say that this code is correctly unbundled from 50080 and 99232 due to appropriate use of the -59 modifier. The Plan denied your request. The Plan says the -59 modifier was not appended appropriately because this was not a truly separate and distinct service.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 

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 procedure code 50561-59-51. Our reviewer says that the use of the -59 modifier in this case was not supported in the medical record. Our physician reviewer found that you reported Current Procedural Terminology (CPT) 50561 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service with modifier 59 for services rendered. Documentation submitted was reviewed and does not meet criteria.

The operative report does not support CPT 50561 as a separate procedure from the primary procedure. Per Medicare "Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M (Evaluation/Management) services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service". Radiology services would be used to perform the primary service and would be included in that code reported. Billing the radiology services separately would result in services unbundled. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 50561-59-51 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 50561-59-51.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychosocial rehabilitation services provided from August 2, 2021 to August 20, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the psychosocial rehabilitation services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.

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 psychosocial rehabilitation services provided from August 2, 2021 to August 20, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertilflex device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pregabalin caplet 25mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.
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 Pregabalin caplet 25mg for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta Onpro.

You asked the Plan to pre-approve Neulasta Onpro. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Neulasta Onpro.

Benefits for Neulasta Onpro 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kevzara 200/1.14 injection 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 this is denied as a benefit exclusion.

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 Kevzara 200/1.14 injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you
had on June 7, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you expected to pay $25, not $150.
The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150
copayment for diagnostic radiological services.
You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the diagnostic
radiological services 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 computed
tomography (CT) scan you had on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the endovascular ablation therapy and the duplex scan you had on June 4, 2020, at a vascular surgeon's office.

You asked the Plan to waive the cost sharing for the endovascular ablation therapy and the duplex scan. You say that this procedure couldn't be completed, so you shouldn't have to pay the copayment. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for the duplex scan, since the allowed amount for this service ($119.77) is less than your copayment obligation, you are responsible for the full allowed 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 $125 copayment for radiological diagnostic services and a $25 copayment for specialist services.

You have been asked to pay a $25 copayment for the endovascular ablation therapy and a $125 copayment for the the duplex scan. The endovascular ablation therapy occurred in a specialist's office and the duplex scan falls within the radiological diagnostic services benefit category. This cost sharing applies even if the procedure cannot be completed as planned. 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 cost sharing for the endovascular ablation therapy and the duplex scan you had on June 4, 2020, at a vascular surgeon's office.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group (DRG) 190 provided from May 26, 2021 to May 27, 2021.

You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the billing of the secondary diagnosis code J96.21: Acute and chronic respiratory failure with hypoxia with DRG 190. The Plan denied your request. The Plan says the medical records do not support the billing of the secondary diagnosis code J96.21: Acute and chronic respiratory failure with hypoxia with DRG 190.

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 J96.21. 

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 hospital services. Our reviewer says that the medical records do not support the billing of the secondary diagnosis code J96.21: Acute and chronic respiratory failure with hypoxia with DRG 190. Our physician reviewer found the review indicates that the documentation supported an admission for Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. The documentation was inconsistent regarding a diagnosis of Acute on Chronic Respiratory Failure with Hypoxia. Even though Acute on Chronic Respiratory Failure with Hypoxia is documented in the Discharge Summary, supporting medical record documentation was not found within the record. The enrollee presented to the Emergency Room with complaint of shortness of breath. The review indicates that the medical records did not support the billing of the secondary diagnosis code J96.21: Acute and chronic respiratory failure with hypoxia with DRG 190. 

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 inpatient hospital services with diagnosis related group (DRG) 190 provided from May 26, 2021 to May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care.
You asked the Plan to pre-approve the continuation of inpatient psychiatric care. You say that these services
are medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage
have not been met.
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 pre-approve the continuation of inpatient psychiatric care. Our reviewer says that the requested inpatient psychiatric care is not medically reasonable and necessary. Our physician reviewer found based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of December 27, 2021, forward. The enrollee could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 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 continuation of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (procedure code 99291) provided to the enrollee on March 18, 2021.

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 Current Procedural Terminology (CPT) code 99291 (1 Units) remains 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, the documentation does not include the time spent providing the service. This information is necessary as CPT 99291 is a time-based code. 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 critical care services (procedure code 99291) provided to the enrollee on March 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit limit has been exceeded.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 50 miles one-way. We looked at your request, the records in the case file, and the rules. The requested trip is for an additional 14 miles. This cannot be covered.
Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient consultation services provided to the enrollee on February 28, 2021.

You asked the Plan to pay for the services. You say that it is the responsibility of the facility to obtain authorization. The Plan denied your request. The Plan says these services were not authorized prior to obtaining the services rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 inpatient consultation services provided to the enrollee on February 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural steroid injections.

You asked the Plan to pre-approve lumbar epidural steroid injections. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that lumbar epidural steroid injections are subject to the criteria listed in the Medicare rules section. 

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 lumbar epidural steroid injections. Our reviewer says that this procedure is not medically reasonable and necessary. Our physician reviewer found that this 59-year-old woman has chronic low back pain. She complains of left sided pain that radiates into her buttock. She has had sacroiliac (SI) joint pain addressed by SI joint injections and has had radiofrequency ablation services. She is status post a spinal fusion procedure with a well healed scar. She has a spinal cord stimulator in place. In this case, there is no literature that supports performing an Epidural Steroid Injection in the presence of an active spinal cord stimulator (SCS) lead. Furthermore, there is no documentation of SCS reprogramming efforts to cover the painful radiculopathy. In addition, there is no documentation of a recent home exercise program or other conservative therapy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural steroid injections.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound you had at an outpatient hospital facility on June 23, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that just because the doctor orders his routine tests to be performed by the hospital, you don't believe you should be charged the outpatient copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for diagnostic procedures and tests at an outpatient hospital. 

You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the diagnostic procedures and tests at an outpatient hospital benefit category. This copayment applies regardless of the reason why you went to the hospital facility for this test. 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 ultrasound you had at an outpatient hospital facility on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the Prolia injection you received on July 12, 2021.

You asked the Plan to reduce the cost sharing for the Prolia injection. You say that prior to getting this shot, you asked how much it would cost. You stated that you were told the cost would be $35. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that there are no records of either you or the provider calling to confirm your cost sharing prior to these services being rendered.

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 20% coinsurance for Medicare Part B drugs. 

You have been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the Medicare Part B drugs 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 reduce the cost sharing for the Prolia injection you received on July 12, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arformoterol 15 mcg/2ml solution 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 coverage of the requested drug is subject to step therapy criteria.
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 the services. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the requested drug is not medically reasonable or necessary. Based on the medical records provided, the enrollee has tried and failed the required drug. Based on the medical records provided, there is no indication that Perforomist 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve Arformoterol 15 mcg/2ml solution for the enrollee.