Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 12, 2020, through July 22, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says that the Medicare guidelines have not been met as the medical records failed to support the need inpatient stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was a then, an 87-year-old female with PMHx significant for T2DM, HTN, and DVT (2018) who presented to the ER 07/12/2020 with cognitive decline and acute right-hand weakness. She underwent a neurologic workup that was largely unrevealing for an acute pathology with nonspecific findings for lack of leukocytosis, fever, and other infectious symptoms including dysuria. Differential was highest for vascular dementia given nonspecific white matter disease on CTH Vs cognitive decline secondary to depression Vs Alzheimer's. Given her dementia and inability to care for herself, the enrollee needed long-term care placement. Per a family meeting on July 21, 2020, the enrollee's brother and sister-in-law did not have the resources and ability to provide 24/7 care for the enrollee on their own. Financial services, case management and social work worked with the enrollee's family to transfer her insurance coverage from California to Massachusetts, a long process requiring several weeks. She was transferred to a long-term care facility on August 24, 2020. The review indicates that the record shows that at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 12, 2020, through July 22, 2020.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0210, D4910) provided to you on October 6, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services are not covered.
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 services are not among those covered under this benefit. The Plan covers only those dental services for which the codes are listed in the Evidence of Coverage. Dental codes D0210 and D4910 are not listed, and therefore are not covered. Therefore, we decided that the Plan does not have to pay for the dental services (D0210, D4910) provided to you on October 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
January 8, 2021, through January 9, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of inpatient hospital admission does not meet the requirement for approval.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that you presented with fever in the setting of CLL undergoing treatment. You were admitted and started on antibiotics and an infectious work-up was obtained. Oncology and Infectious Disease were consulted. Your fever resolved and you had no localizing infectious signs, and your blood cultures were preliminarily negative. You had an elevated D-dimer, which was likely from your cancer. The duplex was negative for DVT and you were having no respiratory symptoms or pleurisy or tachycardia. Your condition stabilized and improved, and you were discharged home on January 9, 2021. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 8, 2021, through
January 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 9, 2020 by an out of network (OON) provider.

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 were rendered by an out-of-network provider without prior authorization.

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 referring provider 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 laboratory services provided on March 9, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the stress test and injection rendered on December 3, 2020.

You asked the Plan to waive the cost sharing for these services. You say that you should not be responsible for the cost sharing. The Plan denied your request. The Plan says the cost sharing was applied 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 Medicare-covered nuclear medicine at a freestanding provider and a 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs.

Review of the file shows that you received a nuclear stress test on December 3, 2020. You have been asked to pay a $100 copayment for these services. These services fall within the Medicare-covered nuclear medicine at a freestanding provider benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The file shows that you received a Regadenoson injection on December 3, 2020. You have been asked to pay a 20% coinsurance for these services, for a total of $47.35. These services fall within the Medicare-covered Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The total amount you have been asked to pay for these services is $147.35. 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 stress test and injection rendered on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99203) and radiologic examination, foot (73630) provided November 17, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the provider charged you and the plan by submitted 7 different medical codes to the plan. The Plan denied your request. The Plan says the claim was processed and the correct cost share was applied per the Evidence of Coverage.
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 $35 copay for each covered podiatry visit for Podiatry services. You have been asked to pay $35 copay for each covered podiatry visit for the office visit. the office visit falls within the Podiatry 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 outpatient office visit (99203) and radiologic examination, foot (73630) provided November 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 sepsis and osteomyelitis. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you have a new prosthetic and need therapy and training for it. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 admission to a Skilled Nursing Facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection of anesthetic agent and steroid into an intercostal nerve (64421) provided on November 24, 2020.

You asked the Plan to pay for the injection of anesthetic agent and steroid into an intercostal nerve. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is not enough information to determine how the member came to the provider, the referring provider, or whether the services were necessary.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, 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. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection of anesthetic agent and steroid into an intercostal nerve have not been met. Specifically, there is insufficient information to verify if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the injection of anesthetic agent and steroid into an intercostal nerve (64421) provided on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diabetic foot inserts (A5513) provided on October 13, 2020.
You asked the Plan to waive the coinsurance for diabetic foot inserts. You say that when you ordered the requested items you were told they would be at no cost. The Plan denied your request. The Plan says the correct coinsurance was applied.
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-covered prosthetic devices and related supplies. You have been asked to pay $53.96, or 20% of the Medicare-allowed amount of $269.76, for diabetic foot inserts. Diabetic foot inserts fall within the "Prosthetic devices and related supplies" 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 coinsurance for diabetic foot inserts (A5513) provided on October 13, 2020.
Your complaint about receiving erroneous or ambiguous information about your cost-sharing responsibility from the provider 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) with
segmental pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device with segmental pneumatic appliance. You
say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan
says rules for pneumatic compression devices have not been met.
The Plan must follow Medicare rules. Medicare rules say that the documentation by the treating practitioner of
the medical necessity of a PCD must include symptoms and objective findings, including measurements which
establish the severity of the condition.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a pneumatic compression device have not been met. Specifically, the case record does not include
objective documentation of a four-week trial of conservative therapy. The requested segmental pneumatic
appliance is not separately payable when the base PCD is not covered. Therefore, we decided that the Plan does
not have to pre-approve a pneumatic compression device (E0651) with segmental pneumatic appliance
(E0667).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 respiratory failure, pneumonia and pulmonary edema. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea Freestyle Libre 14 day/sensor/flash monitoring system for the enrollee.You asked the Planto pre-approvethe system. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not reveal that the enrollee takes insulin, or how often she checks blood glucose levels. There is no information as to why this monitor is needed.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 system have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea Freestyle Libre 14 day/sensor/flash monitoring system for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injections of a lower or sacral spine facet joint (64494) provided on June 9, 2020.
You asked the Plan to pay for the injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare rules for payment of the billed 2 units of service of CPT code 64494 for June 09, 2020, has not been met.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64494 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for the injections of a lower or sacral spine facet joint (64494) provided on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit and arthrocentesis provided by an out-of-network provider on August 26, 2020.You asked the Plan to pay forthe office visit and arthrocentesis. You say that you submitted medical notes for further review.The Plandenied your request. The Plan says care received from a non-network provider will not be covered.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 did not pre-approve the item/service at issue. We foundno exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe office visit and arthrocentesis provided by an out-of-network provider on August 26, 2020.