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

 We decided that the Plan does not have to pay for anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) (CPT code 99100) provided to the enrollee on May 7, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is 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. CPT code 9100 has a status indicator of 'B' on the CMS Physician Relative Value File, and is always bundled into payment for other services not specified and no separate payment is made per Medicare. 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 anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) (CPT code 99100) provided to the enrollee on May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a wheelchair and accessories to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the OON wheelchair and accessories. You say that the documentation provided supports the need for the custom medical equipment being requested. The Plan denied your request. The Plan says medically necessary services are available within the enrollee's network and there are no extenuating circumstances making it medically necessary to obtain the services OON.  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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. 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 a wheelchair and accessories to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit (99205) provided on  July 22, 2021.  You asked the Plan to waive the copayment for the office visit. You say that you should not be charged a copayment The Plan denied your request. The Plan says the copayment has processed 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 $25 copayment for specialist office services.   You have been asked to pay a $25 copayment for the office visit. This service falls within the specialist office 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 office visit (99205) provided on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.  You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that the enrollee has diabetes. The Plan denied your request. The Plan says insufficient information has been received to show that the requirements for coverage have been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess adherence to their CGM regimen and diabetes treatment plan.   We looked at the file and Medicare rules. The documentation does not show that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, requires frequent self-adjustment of insulin dosage based on the blood glucose testing results, and has had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
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 services are 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 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 there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.     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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiation therapy to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve radiation therapy to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.  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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. 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 radiation therapy to be provided 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 domiciliary or rest home visit (99336) provided on  July 27, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary or rest home visit. You say that you would like this claim reprocessed for medical necessity. 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 domiciliary or rest home visit (99336) provided on July 27, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve a technetium pyrophosphate study.  You asked the Plan to pre-approve a technetium pyrophosphate study. You say that the medical records provided support the need for the requested services. The Plan denied your request. The Plan says that the requested services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 a technetium pyrophosphate study. Our reviewer says that a technetium pyrophosphate study is considered medically reasonable and necessary in this case. Our physician reviewer found It is documented by the cardiologist that the enrollee has evidence of ongoing volume overload and has had an abnormal nuclear stress test. The documentation supports that the requested technetium pyrophosphate study is medically reasonable and necessary for the enrollee in this case. The Plan's denial rationale is not sufficient for denial of the requested technetium pyrophosphate study.  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 technetium pyrophosphate study have been met. Therefore, we decided that the Plan has to pre-approve a technetium pyrophosphate study.   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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee requires physician supervision by a rehabilitation physician with face-to-face visits at least 3 days per week. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could receive care in another setting.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for gangrene and osteomyelitis and had amputation of left 2nd toe. He had a fall in the hospital and had wrist scapholunate dissociation. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism (CPT code 87798) provided to the enrollee on January 29, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, the service, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism (CPT code 87798) provided to the enrollee on January 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of SNF care from December 31, 2021, forward.  You asked the Plan to pre-approve SNF care. You say that the enrollee was discharged from skilled care on December 30, 2021, and went on custodial care after at the facility. You state that after the discharge the enrollee had a change in condition and ended up with Coronavirus (COVID). You state that you do not feel you should be responsible for the stay since the enrollee was ill and now that the enrollee has tested negative for Coronavirus and has recovered. You state they are really weak and needs physical therapy. The Plan denied your request. The Plan says the enrollee does not require 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from December 31, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator.  You asked the Plan to pre-approve a portable ventilator. You say that the enrollee's current equipment is not working to the severity of his condition. You say that the requested device is needed to prevent future hospitalizations. The Plan denied your request. The Plan says a home mechanical ventilator set in intelligent volume-assured pressure support (IVAPS) mode that could be delivered by bi-level positive airway pressure (BiPAP) is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 portable ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically necessary.  The enrollee is currently on bi-level positive airway pressure (BiPAP) for obstructive sleep apnea (OSA.) A blood gas report from November 22, 2021 shows a PCO2 of 62, but this is likely a venous sample because the pO2 is 48, and the enrollee was not acutely ill.  It appears the blood gas is the sole reason the ventilator is being ordered.  However, even if the enrollee is retaining CO2, Medicare does not cover a home ventilator when used as BiPAP.  Certain BiPAP devices can provide the average volume-assured pressure support (AVAPS) mode of support.  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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for 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 (CPT code 99072) provided to the enrollee on February 11, 2021.  You asked the Plan to pay for the service. You say that at the request of the surgeon you were asked to participate and provide services in the procedure. The Plan denied your request. The Plan says the service is 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. CMS assigns a status code of B for this code which states that payment for covered services is always bundled into payment for other services not specified. The provider billed and was paid for 00811-AA-P3-33. Therefore, codes 99072 will be disallowed when billed in conjunction with another CPT and/or healthcare common procedure coding System (HCPCS) procedure code. Modifier 59 will not be allowed to override these edits. 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 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 (CPT code 99072) provided to the enrollee on February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve proton beam therapy.  You asked the Plan to pre-approve proton beam therapy. 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 proton beam therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than intensity modulated radiotherapy/image-guided radiation therapy (IMRT/IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. The LCD criteria are not met.      We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve seventeen (17) home health (HH) physical therapy (PT) visits.  You asked the Plan to pre-approve the services. You say that you do not have a power lift chair, only a wheelchair to help you move around. You state you need maintenance therapy to keep the muscles in your legs and this is something that you cannot do yourself. You state your doctor and physical therapist are saying you need this. The Plan denied your request. The Plan says the services are not necessary because it seems as though you may be at your functional baseline (your normal ability), you use a wheelchair, your home is wheelchair accessible, and you have assistance from family members.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 physician reviewer found the health plan's denial should be upheld. You do not have documented, ongoing, HH PT needs. You have appropriate durable medical equipment (DME) and custodial care needs. Ongoing, HH PT services are not medically necessary or reasonable.  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 seventeen (17) home health (HH) physical therapy (PT) visits.