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

We decided that the Plan does not have to pay forOphthalmology services (92201) provided May 4, 2020.You asked the Plan to pay forthe Ophthalmology services. You say that the services were medically necessary.The Plan denied your request. The Plan says an invalid modifier was 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.We find that CPT code 92201 is not supported in the medical record. Specifically, the procedure was billed with an invalid modifier (RT). Based on this information, we decided that Medicare rules for coverage of the Ophthalmology services have not been met.Therefore, we decided that the Plan does not have to pay forOphthalmology services (92201) provided May 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 determineif the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided necessitating admissionto a LTACH. The enrollee still requires acute level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 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.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, wedecided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the consultation (D9310) and the cone beam CT (D0364) provided on August 21, 2020.
You asked the Plan to pay more for the dental services. You say that you were advised that that the service was approved. You say that you also received a bill for $86.80. You also say that you were advised you would be reimbursed $491. The Plan denied your request. The Plan says the consultation is not listed as a covered service. The Plan says that the cone beam CT is not listed as a covered service either. The Plan says you have additional coverage through another plan. The Plan also says that after your additional coverage was applied, your responsibility is $86.80.
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 services you received are not among those covered under this benefit. The record shows that the Plan applied $14 towards the services you received. The record shows that your additional coverage by another plan applied $289.20. This leaves you with a member liability of $86.80. Therefore, we decided that the Plan does not have to pay more for the consultation (D9310) and the cone beam CT (D0364) provided on August 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from July 27, 2020 to August 4, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that your surgery was initially scheduled after the Plan's enhanced COVID-19 relief benefits were set to begin, but you had to have the surgery sooner due to urgent medical concerns. The Plan denied your request. The Plan says that there is a $350 copay for each of the first 5 days of an inpatient hospital stay. The Plan also says that the enhanced benefits did not start until August 17, 2020, which is after the dates of service at issue.
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 $350 copayment for each of the first 5 days of inpatient hospital care. You have been asked to pay a $350 copayment for each of the first 5 days for inpatient stay. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided from July 27, 2020 to August 4, 2020.
Your complaint about whether or not the Plan should grant an exception to their enhanced benefit start date 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided September 9, 2020.
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says this service is not eligible for separate payment.
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 71045 has a Column One/Column Two relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided September 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that inpatient rehab is medically necessary for the enrollee.The Plan denied your request. The Plan says your request for approval of an IRF admission does not meet the requirements for approval.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. Our reviewer found that the documentation is not clear that the enrollee's renal and respiratory status are stable prior to transfer to an IRF. Our physician reviewer also found that while the enrollee may benefit and participate in multiple therapies, the enrollee's functional level does not require or appear to tolerate therapy on an 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-approveacute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benralizumab for the enrollee.
You asked the Plan to pre-approve the drug. You say that the medical records provided support the need for the requested drug. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Benralizumab is not indicated for the treatment of other eosinophilic conditions or for the relief of acute bronchospasm or status asthmaticus. In this case, the reviewed documentation does not show that the enrollee has an eosinophil count of at least 150 cells/microliter during the previous 6 weeks or at least 300 cells/microliter during the previous year. There is no evidence of failure to other required therapies (12 months of high dose inhaled corticosteroids used in combination with a long-acting beta agonist, 12 months of high-dose inhaled corticosteroids used in combination with a leukotriene modifier, 12 months of high-dose inhaled corticosteroids used in combination with theophylline for a minimum of 3 months, or 6 months of high-dose inhaled corticosteroids with daily oral corticosteroids used in combination with at least one additional controller medication)(patient is not taking oral steroids). The records also do not show severe persistent asthma (symptoms several times per day that occur almost every day and many nights) or has abnormal peak flow rate (office visit 01/17/21, shows asthma is mild and peak flow rate had no abnormalities). 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Benralizumab for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on March 15, 2020.You asked the Plan to pay forthe ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 15, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on March 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound rendered on September 14, 2020.
You asked the Plan to waive the copayment for these services. You say that you did not request this test. The Plan denied your request. The Plan says the copayment 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 in-network basic radiological services at an outpatient hospital.
Review of the file shows that you had a breast ultrasound on September 14, 2020. Per the contract with the Plan, there is a $100 copayment for in-network basic radiological services at an outpatient hospital. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $76.99. Given that the allowed amount was less than the $100 copayment, you have been asked to pay $76.99 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the breast ultrasound rendered on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Purewick External Catheter System (HCPCS E1399).

You asked the Plan to pay for the system. You say that this should be paid for. The Plan denied your request. The Plan says this is correctly coded as A9270; therefore, it is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the system. Our reviewer says that the requested services were not properly coded. Our coding reviewer found the documented submitted was reviewed and does not meet criteria. This item is a non-cover item at this time. A9270 would be the correct code to report.

We looked at this coder'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 Plan does not have to pay for the Purewick External Catheter System (HCPCS E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical extraction (D7210) of tooth # 25.
You asked the Plan to pre-approve the dental service. You say that the extraction of tooth # 25 is medically necessary. The Plan denied your request. The Plan says the surgical extraction is not listed as a covered benefit.
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 frequency limit of 6 extractions per calendar year has been reached. The record shows that the Plan approved extractions for teeth # 9, 12, 14, 23, 24 and 26. Therefore, we decided that the Plan does not have to pre-approve the surgical extraction (D7210) of tooth # 25.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foran urgent care office visit (99203) and lab services (81002, 87086) provided on October 26, 2020.You asked the Plan to waive the copayments forurgent care visit and lab tests. You say that you should not have to pay the copayments. The Plan denied your request. The Plan says the copayments were 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 $45 copayment for an urgent care visit for urgently needed services and a $10 copayment for laboratory tests.You have been asked to pay a $45 copayment for an urgent care visit, and a $10 copayment for laboratory tests. The services at issue fall within the urgently needed services and laboratory tests benefit categories. 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 agreedto pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments foran urgent care office visit (99203) and lab services (81002, 87086) provided on October 26, 2020. Your complaint about being referred to urgent care instead of the emergency room 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must followMedicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if thePlan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does notrequire an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for COVID 19 pneumonia and pulmonary embolism. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical recorddocuments a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1.Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Section 423.578(b)(5)(ii).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You can find this information on page 72 of the Plan's2021 Evidence of Coverage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), intraoral-complete series of radiographic images (D0210), and the unspecified preventive procedure (D1999) rendered by the out of network (OON) provider on September 30, 2020.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), intraoral-complete series of radiographic images (D0210), and the unspecified preventive procedure (D1999) rendered by the out of network (OON) provider on September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean osteogenesis stimulator.You asked the Plan to pre-approvethe stimulator. You say that this helps with bone growth and healing.The Plan denied your request. The Plan says there is no failed fusion.The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 stimulator. Our reviewer says that the requested item is not medically reasonable or necessary. Our physician reviewer found there is a lumbar fusion on only 2 levels and there is no non-union. The stimulator is not 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 stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approvean osteogenesis stimulator.