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

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  

You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you no longer require daily skilled 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. 

Continued SNF services beyond February 9, 2022, were requested. 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 continued services. Our physician reviewer found that you received skilled nursing facility care due to a right tibia fracture. You were initially non-weight bearing with the right lower extremity but is now weight bearing as tolerated in a knee brace. You require a wheelchair for mobility and were at a maximum assist level for transfers and some activities of daily living. There is no documentation that you require skilled nursing services of a skilled professional nurse to provide medically necessary treatment. Although you do require skilled therapy services, you do not require skilled nursing or therapy services on a daily 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home physical therapy (PT) services.  You asked the Plan to pre-approve the home PT services. You say that the ongoing PT is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has met all home health PT goals and can ambulate with a walker. The Plan also says that home exercises can be safely managed by unskilled personnel or caregivers.  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 home PT services. Our reviewer says that the requested, ongoing, home health physical therapy (PT) is not medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented, ongoing, home health PT needs. Our reviewer also found that the enrollee is functioning at a level commiserate with a lower level of care.  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 home PT services have not been met. Therefore, we decided that the Plan does not have to pre-approve home physical therapy (PT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on July 16, 2021.

You asked the Plan to pay for office visit. You say that you billed this claim with the appropriate place of service code. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 99203 is not appropriate for an emergency room place of service.

The Plan must follow Medicare rules. Medicare rules say that practitioners seeing a patient registered in an emergency department should use an emergency department visit code. 

We looked at the file and Medicare rules. This claim for an emergency department visit should be billed with an emergency department evaluation and management visit code. Based on this information, we decided that Medicare rules for coverage of office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99203) provided on July 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a heavy-duty hospital bed with mattress.  You asked the Plan to pre-approve heavy-duty hospital bed. You say that you cannot roll over in a regular hospital bed. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because your weight is less than 350 pounds, so you do not meet criteria for a heavy-duty extra wide hospital bed.  The Plan must follow Medicare rules. Medicare rules say that a heavy-duty extra wide hospital bed is covered if the enrollee's weight is more than 350 pounds but does not exceed 600 pounds.   We looked at the file and Medicare rules. Your weight is less than 350 pounds. Based on this information, we decided that Medicare rules for coverage of heavy-duty hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty hospital bed with mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the chair portion of a lift chair (A9270).  You asked the Plan to pre-approve the chair portion of a lift chair. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the chair portion of a lift chair (A9270).
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 this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which an LTACH may offer a therapeutic advantage.  

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is improving and continues to receive acute care services which have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied; the requested service cannot be recommended.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Annual Wellness Visit (G0439) provided on September 9, 2021.  You asked the Plan to pay for the Annual Wellness Visit. You say that you would like reconsideration because you do not believe that you should be held responsible for this charge. The Plan denied your request. The Plan says the maximum benefit for this service has been exhausted.    The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months.   Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the Annual Wellness Visit (G0439) provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a cervical epidural steroid injection (ESI) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.  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 cervical epidural steroid injection (ESI) 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 service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility coded 99053 provided on February 27, 2021.  You asked the Plan to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility. 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 payment for this service is bundled into other services not specified. No separate payment can be made. 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 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 coded 99053 provided on February 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99203) radiologic examination, spine, cervical (72040) radiologic examination, spine, thoracic (72070) radiologic examination, spine, lumbosacral (72100) radiologic examination, shoulder (73020) transcutaneous electrical nerve stimulation (tens) device (E0730) trigger point injections (20553) lumbar sacral orthosis (L0637) provided July 28, 2021 to August 10, 2021.  You asked the Plan to pay for the outpatient visits. You say that you verified out of network benefits and was told by a Plan representative that the enrollee had out of network benefits for our office. The Plan denied your request. The Plan says lack of medical documentation. The Plan cannot determine if a physician's order was given, how the enrollee came to you, the referring or supervising physician or whether the services were necessary.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that the services provided not supported in the medical record. Specifically, there is no clinical records provided from the provider. All providers are required to furnish necessary information to the Plan when requested. The records show the Plan made multiple attempts to obtain medical records from the provider without success. Based on this information, we decided that Medicare rules for coverage of the outpatient visits have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99203) radiologic examination, spine, cervical (72040) radiologic examination, spine, thoracic (72070) radiologic examination, spine, lumbosacral (72100) radiologic examination, shoulder (73020) transcutaneous electrical nerve stimulation (tens) device (E0730) trigger point injections (20553) lumbar sacral orthosis (L0637) provided July 28, 2021 to August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital outpatient clinic visit for assessment and management of a patient (CPT code G0463) provided to the enrollee on February 3, 2020.  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 Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds twelve (12) months or 1 calendar year from the date the services were furnished.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the service was not filed until August 18, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit for assessment and management of a patient (CPT code G0463) provided to the enrollee on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met for the requested device.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit provided from November 21, 2018, to November 23, 2018.  You asked the Plan to waive the copayment for emergency room visit. You say that the enrollee is receiving a bill for the balance of this bill. The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). The enrollee's contract with the Plan clearly says that you must pay $80 copayment for emergency room visit. The rules say that for a non-contracting, original Medicare participating provider there is no balance billing paid by either the Plan or the enrollee.  The enrollee has been asked to pay $80 copayment for emergency room visit. Emergency room visit falls within the Emergency Care benefit category. This means that the enrollee has been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when they enrolled in the Plan. Additionally, neither the Plan nor the enrollee is responsible for the balance bill amount of this claim. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided from November 21, 2018, to November 23, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on May 29, 2021.

You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 medical records submitted do not support a critical care visit of 30-74 minutes was performed. The records do not include the time spent providing this service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on May 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power mobility device.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the enrollee has a mobility deficit of ataxia. The documentation does not support that she has a mobility deficit that impairs participation in mobility-related activities of daily living (MRADLs) that cannot be helped by the use of a manual wheelchair. The enrollee uses a walker, and her upper body strength supports that she should be able to use a manual wheelchair. The records do not support that the requested power mobility device is reasonable or medically necessary at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle 2 Libre sensor (k0553).  You asked the Plan to pre-approve a Freestyle 2 Libre sensor. You say that the item is medically necessary. The Plan denied your request. The Plan says you take fixed-dose insulin twice per day, and you do not adjust your insulin dose based on your blood glucose results.  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 indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 2 Libre sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 2 Libre sensor (k0553).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the breast ultrasound (76641) provided on September 16, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $50 copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service.    You have been asked to pay a $50 copayment for the ultrasound provided. 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 breast ultrasound (76641) provided on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the replacement calf pads (E0995).  You asked the Plan to pre-approve the replacement calf pads. You say that the item is medically necessary. The Plan denied your request. The Plan says this is a replacement code and cannot be used on initial issue.  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 E0995 is a column II code to column I code K0856. This means that Medicare rules for coverage of the replacement calf pads have not been met. Therefore, we decided that the Plan does not have to pre-approve the replacement calf pads (E0995).