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

We decided that the Plan does not have to pre-approve. Neulasta.
You asked the Plan to pre-approve. Neulasta. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is considered experimental/investigational.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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. Neulasta. Our reviewer says that this requested drug is not medically necessary and reasonable. Our physician reviewer found the patient has been diagnosed with acute myeloid leukemia (AML). In this case, Neulasta it is not indicated for myeloid malignancy. There is no support for the requested drug according to Medicare rules. An alternative would be considered 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 Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve. Neulasta.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for hemodialysis (99512) provided from April 2, 2021, to April 14, 2021.
You asked the Plan to pay for home health services. You say that you would like the Plan to reprocess these claims. The Plan denied your request. The Plan says services rendered by a provider not enrolled in Medicare are not eligible for payment.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home visit for hemodialysis (99512) provided from April 2, 2021, to April 14, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair with multiple power options and the other requested items/accessories (CPT code(s): K0861, 97542, E2377, E2313, K0108, E1028, E1002, E2300, E2613, K0108 X 4, E0955, E1028, E2311), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says the Group 3 Power Wheelchair with multiple power options is not reasonable and necessary, none of the requested accessories can be covered. The Plan states the enrollee's needs can be met with a Group 3 Power Wheelchair with single power option. The Plan states the enrollee does not have medical need for multiple power options included with K0861 group 3 power wheelchair. E2300 Seat Elevator does not serve a primary medical purpose and cannot be covered. E2311 Electronic connection, E2377 Expandable Controller and E2313 Expandable Controller Harness cannot be covered as it is not medically necessary to control three power options through the joystick (drive interface).
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 DME. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a powered wheelchair with multiple power options was requested, but only single power option was approved. The provided records show that the enrollee is able to operate the wheelchair using her hand and would not require multiple power options. Therefore, the enrollee does not meet the criteria for a powered wheelchair with multiple power options as requested. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair with multiple power options and the other requested items/accessories (CPT code(s): K0861, 97542, E2377, E2313, K0108, E1028, E1002, E2300, E2613, K0108 X 4, E0955, E1028, E2311), for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for Vitamin B-12 injections provided April 14, 2021.
You asked the Plan to pay for Vitamin B-12 injections. You say that you would like this claim reprocessed as similar claims have been paid in the past. The Plan denied your request. The Plan says that Medicare criteria have not been met.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has not fully substantiated their denial. First, the Local Coverage Determination that they are citing is for a state that you do not reside in and does not have jurisdiction. Furthermore, medical records would have been necessary to determine your medical condition before a decision was made. These records were not requested by the Plan. Therefore, we decided that the Plan has to pay for Vitamin B-12 injections provided April 14, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that a SNF will help gain your strength back. The Plan denied your request. The Plan says that there are no noted skilled nursing or therapy needs that need to be provided on a daily basis in an inpatient setting.
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 physician reviewer found that you are at a maximal assist level for eating, minimal to moderate assist for sitting up and standing, independent for sitting, and minimal to contact guard assist for walking. You do not have documented skilled nursing needs. However, you do have documented skilled therapy needs. You appear to be functioning below your baseline. There is insufficient documentation to show that you have reached a new plateau in function. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your condition. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) services.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Aminophyllin injection services represented by code J0280, therapeutic, prophylactic, or diagnostic injection services represented by code 96374, and an additional sequential intravenous push of a therapeutic, prophylactic, or diagnostic injection represented by code 96375 and billed for date of service February 23, 2021.
You asked the Plan to pay for codes J0280, 96374, and 96375. You say that the medical records provided support the services which remain in dispute. The Plan denied your request. The Plan says the criteria for coverage of the codes in dispute have not been met.
The Plan must follow Medicare rules. The rules state that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The rule state that an add-on code is only eligible for payment if one of the listed primary procedure codes is also eligible for payment to the same practitioner for the same patient on the same date of service. The medical records provided do not show that 2 units of an Aminophyllin injection were provided on the date of service billed. This means that this code billed with 2 units is not corroborated by the documentation in the beneficiary's medical records. The medical records provided do not show that the therapeutic, prophylactic, or diagnostic injection services billed with code 96374 and with the -59 modifier is a distinct procedural service. The records did not demonstrate that two or more procedures were performed at different anatomic sites or different patient encounters. Therefore, the use of modifier -59 is not appropriate in this case and payment for this code is considered to be included in the payment made on codes 93015, 78492, and 78434 and cannot be separately reimbursed. The definition of code 96375 is that of an add-on code and states that the code should be listed separately in addition to the code for primary procedure. In this case the primary procedure code is 96374, which was not eligible for payment. Therefore, the add-on code is also not eligible for payment. Based on this information, we decided that Medicare rules for coverage of the services which remain in dispute have not been met. Therefore, we decided that the Plan does not have to pay for Aminophyllin injection services represented by code J0280, therapeutic, prophylactic, or diagnostic injection services represented by code 96374, and an additional sequential intravenous push of a therapeutic, prophylactic, or diagnostic injection represented by code 96375 and billed for date of service February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost-sharing amount applied to the Guardant360 genetic testing provided on January 26, 2021.
You asked the Plan to adjust the cost-sharing amount applied to the Guardant360 genetic testing. You say that the provider who supplied the Guardant360 is the exclusive provider of this genetic test. You say that this test was deemed medically necessary. You say that the enrollee did not have an in-network option. The Plan denied your request. The Plan says the appropriate cost-sharing amount was applied to the genetic testing provider.
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 enrollees must pay a 20% coinsurance for molecular and predisposed genetic testing. The cost-sharing amount billed was not calculated based on an out of network benefit. The total allowed amount for the Guardant360 test provided was $3,500. The enrollee has been asked to pay 20% of this allowed amount, which totaled $700. The Guardant360 test falls within the molecular and predisposed genetic testing benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to adjust the cost-sharing amount applied to the Guardant360 genetic testing provided on January 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the X-ray services coded as 73502 provided May 27, 2021.
You asked the Plan to pay for the X-ray services. You say that this procedure was rendered in the appropriate place of service. The Plan denied your request. The Plan says the claim was billed incorrectly.
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 looked at the file and the rules. The claim shows the place of service for the x-ray was billed as an outpatient service. However, the file shows that the enrollee was an inpatient at the time the services were provided. Based on this information, we decided that Medicare rules for coverage of the X-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray services coded as 73502 provided May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for a CGM.
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 perform blood glucose testing at least four times per day, does not use insulin with at least three daily injections, does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results, and has not 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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 10, 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 services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on September 23, 2020.
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 procedure codes 97110, 97140, and G0283 are 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The definition of code 97140 is manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. The definition of code G0283 is electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care. We find that procedure codes 97110, 97140, and G0283 are not supported in the medical record. Specifically, there is no documentation of total treatment time to support the billed codes. 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 pay for the physical therapy services rendered on September 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug services rendered on October 8, 2020.
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 procedure codes J3411, J3415 and J1955 are 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 J3411 is injection, thiamine hcl, 100 mg. The definition of code J3415 is injection, pyridoxine hcl, 100 mg. The definition of code J1955 is injection, levocarnitine, per 1 gm. We find that procedure codes J3411, J3415 and J1955 are not supported in the medical record. Specifically, the records show that a nutria-pharmaceutical blend was administered and there is a more appropriate code for these services. Individual codes are not billable. 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 pay for the drug services rendered on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the sedation and drug services rendered on November 20, 2020.
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 procedure codes J2250 and 99512 are 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 J2250 is injection, midazolam hydrochloride, per 1 mg. The definition of code 99152 is moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. We find that procedure codes J2250 and 99152 are not supported in the medical record. Specifically, there is no documentation of an injection of midazolam HCl per 1 mg to support code J2250. There is no documentation of an independent trained observer to assist in monitoring of the patient's level of consciousness and physiological status for the initial 15 minutes to support code 99152. 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 pay for the sedation and drug services rendered on November 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transfer to a different acute care hospital.
You asked the Plan to pre-approve a transfer to a different acute care hospital. You say that it is medically necessary for the enrollee to transfer to a higher level of care. The Plan denied your request. The Plan says the enrollee is receiving the proper acute care at the current inpatient hospital and there is no reason for a transfer at this time.
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 transfer to a different acute care hospital. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the patient is an 80-year-old female who was admitted to an acute care hospital for a variety of medical conditions. Recent notes state that the patient is still being treated in the intensive care unit and is not stable. Transfer to a different acute care hospital was requested by the family. Upon review of the request, there was no submitted supportive information suggesting the other hospital would have more appropriate treatments available compared to the current facility treatments already being received. Therefore, this request for transfer is not supported and will be considered not
medically necessary based on the provided documentation. 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 transfer to a different acute care hospital have not been met. Therefore, we decided that the Plan does not have to pre-approve a transfer to a different acute care hospital.
Your complaint about the quality of the doctors treating the enrollee is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (CPT code D9310) provided on February 11, 2021.
You asked the Plan to pre-approve the dental services. You say that you called the Plan and they advised you that the service is not covered. You state this should be paid or not billed to you because you did not request a consultation. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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 among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pre-approve consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (CPT code D9310) provided on February 11, 2021.