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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for sepsis, urinary tract infection and a lower extremity abscess. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (71045) provided on April 15, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column two
code and is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair,
the column two code is denied, and the column one code is eligible for payment. Procedure code 71045 is part
of an edit pair with procedure code 74022. Procedure code 74022 is a column one code, and procedure code
71045 is a column two code. Procedure code 74022 has been billed for this date of service, which means that
procedure code 71045 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for
the services (71045) provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on November 5, 2020, and November 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
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 records do not show that 30-74 minutes of critical care services were provided on the dates of service in question. Based on this
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on November 5, 2020, and November 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 26, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this should be reported with CPT 81479.
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81301, 81321, 81293, 81201) provided on February 10, 2021.

You asked the Plan to pay for Guardant360 testing. You say that this was medically necessary and is supported by research. The Plan denied your request. The Plan says this was not billed correctly.

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 codes 81301, 81321, 81293, and 81201 are not supported in the medical record. Specifically, these codes were used to report Guardant360 testing, which should be billed with code 81479. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81301, 81321, 81293, 81201) provided on February 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional PT visits.
You asked the Plan to pre-approve twelve (12) additional PT visits. You say that you have very little range of motion and you are in need of additional PT visits. The Plan denied your request. The Plan says the additional PT visits do not meet medical necessity criteria under Medicare.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 twelve (12) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior extensive outpatient therapy visits and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You should be able to transition to an independent home exercise program at this point. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of twelve (12) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on December 15, 2020.
You asked the Plan to pay for the hearing aids. You say that you were under the impression you could have hearing services done at any location. You say that the Evidence of Coverage lists out-of-network hearing aid benefits and you should be reimbursed. The Plan denied your request. The Plan says hearing aids are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though the hearing aid may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on December 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ruxience (Q5119).
You asked the Plan to pre-approve Ruxience. You say that you were told by your provider that you could get
Ruxience and it would be covered. The Plan denied your request. The Plan says there is not enough support for
Ruxience for use in the treatment of peripheral neuropathy associated with anti-myelin-associated glycoprotein
(MAG) antibody and Immunoglobulin M (IgM) paraproteinemia.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 Ruxience. Our reviewer says that
Ruxience (Q5119) is not medically reasonable and necessary. Our physician reviewer found the requested use
of Ruxience is not FDA-approved for use in anti-MAG neuropathy. Our reviewer found that the use is not
supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare &
Medicaid Services (CMS) approved medical journal. Our physician reviewer also found that the compendia do
not support or not support the use of Rituximab in anti-MAG neuropathy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ruxience have not been met. Therefore, we decided that the Plan does not have
to pre-approve Ruxience (Q5119).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on January 13, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided to you on January 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement of the copayment for the outpatient surgery
provided on April 8, 2021.
You asked the Plan to issue reimbursement. 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 $200
copayment for in-network outpatient surgery.
You have been asked to pay a $200 copayment for the outpatient surgery 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 issue reimbursement of the copayment for the outpatient surgery
provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for contact lens fitting. We decided that the Plan does not
have to waive the copayment for the eye exam and eye refraction services.
You asked the Plan to waive the copayment for contact lens fitting. You say that you would like this claim
reprocessed and approved for payment. The Plan says that the claim has processed correctly, and no additional
reimbursement is due.
We decided that the Plan has to reimburse you for the contact lens fitting.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services with an allowance of $100 for services rendered.
We looked at the file and the Plan's rules. The file indicates that this was a contact lens fitting that would fall
under the $100 benefit. We did not see where this service would be denied for payment. Based on this
information, we decided that the Plan's rules for coverage of contact lens fitting have been met. Therefore, we
decided that the Plan has to reimburse you for the contact lens fitting.
We also decided that the Plan does not have to waive the copayment for the eye exam and eye refraction
services.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when received from an OON provider with a $75 allowance. Any
amount over $75 is your responsibility.
We looked at the file and the Plan's rules. The file indicates that the Plan has already reimbursed you $75 for
the eye exam and eye refraction services. The remaining amount is what you owe for services received from an
OON provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam and
eye refraction services has processed correctly and no additional reimbursement is due. Therefore, we decided
that the Plan does not have to waive the copayment for the eye exam and eye refraction services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can continue to be met in the skilled facility.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lower extremity weakness and swelling. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and panoramic x-ray provided on April 1, 2021.

You asked the Plan to pay for the periodic oral evaluation and panoramic x-ray. You say that the provider is in-network and the claim shouldn't be denied. The Plan denied your request. The Plan says out-of-network dental services are not covered benefits.

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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and panoramic x-ray provided on April 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on February 28, 2020.

You asked the Plan to pay for the therapeutic procedure. 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that the services were performed by a physical therapist assistant in a home health or hospice setting. This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on February 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dexamethasone tablets.

You asked the Plan to pre-approve self-administered drugs. You say that the enrollee needs this drug to reduce swelling and prevent proctitis, radiation prostatitis, and necrosis. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve dexamethasone tablets.

Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99205) and the unlisted special service (99199) rendered by the OON provider on October 5, 2020.
You asked the Plan to pay for these 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 for the office visit (99205) and the unlisted special service (99199) rendered by the OON provider on October 5, 2020.