Persius/hicric huggingface dataset:
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 the SNF admission. You say that a subacute rehab stay would be helpful in
returning the enrollee to ambulatory status, which is needed for home care. The Plan denied your request. The
Plan says the enrollee does not require daily skilled services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 84-year-old
female with dementia and acute kidney injury. From a nursing perspective, the beneficiary received oral
medications. The beneficiary had stable vital signs. She was alert with confusion. Regarding rehabilitation
services, the beneficiary received PT and OT in the acute hospital. The beneficiary was dependent with
functional mobility. The beneficiary required varying assist with ADLs.
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs;
however, the beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility
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 the SNF admission 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a
participating provider on June 18, 2020.
You asked the Plan to waive the copayment for specialist services. You say that you did not have to pay for this
the last time. The Plan denied your request. The Plan says the correct copayment has been 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 a $35
copayment for physician/practitioner services/specialist visit.
You have been asked to pay a $35 copayment for specialist services. Specialist services fall within the
physician/practitioner services/specialist visit 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 specialist services provided by a participating provider on June 18, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for trastuzumab-anns biosimilar (Kanjinti) (a
Medicare Part B prescription drug) and chemotherapy infusion services provided from July 23, 2020, to July
30, 2020.
You asked the Plan to waive the coinsurance for Part B drugs and chemotherapy administration. You say that
you are requesting an appeal for these charges. The Plan denied your request. The Plan says the coinsurance
amounts you are being charged are correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Part B drugs and administration services provided by an outpatient hospital. The allowed
amounts of these services total $4,632.92, resulting in a total coinsurance obligation of $926.58.
You have been asked to pay 20% coinsurance for Part B drugs and chemotherapy administration. Part B drugs
and chemotherapy administration fall within the "Medicare Part B Prescription Drugs" and "Outpatient
Hospital Services" 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 agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for trastuzumab-anns
biosimilar (Kanjinti) (a Medicare Part B prescription drug) and chemotherapy infusion services provided from
July 23, 2020, to July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia (01810) provided on January 29, 2020.
You asked the Plan to pay for anesthesia. You say that this service was correctly billed for 27 minutes. The
Plan denied your request. The Plan says the billed units are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.
We find that 27 minutes/units of CPT code 01810 are not supported in the medical record. The medical record
only supports 24 minutes/units of CPT code 01810. Based on this information, we decided that Medicare rules
for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for
anesthesia (01810) provided on January 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429) provided January 7, 2020.
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the CPT code 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 A0429 is not supported in the medical record. Specifically, Medicare requires
ambulance providers use CPT code A0428 with the QL modifier to report cases where the enrollee was
determined to be deceased after the ambulance was called, but prior to transport. Based on this information, we
decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided
that the Plan does not have to pay for ambulance services (A0429) provided January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental extraction provided by an opted-out dentist on August 19, 2020.
You asked the Plan to pay for dental extraction. You say that this was an emergency and the dentists in your plan were closed and unable to see you. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this dentist has opted out of Medicare and is not eligible for payment.
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. Your contract with the Plan says that dental services may be reimbursed if you use a licensed dental provider who is eligible under Medicare. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a dental extraction provided by an opted-out dentist on August 19, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency services provided on September 9, 2020.You asked the Plan to waive the copayment foremergency services. You say that you are being charged more than your copayment.The Plan denied your request. The Plan says this processed correctly. Please note that the Plan has indicated that they have confirmed the provider has agreed to waive additional charges beyond your copayment.The rules say a planmust 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 $90 copayment for emergency care. You have been asked topay a $90 copayment for emergency services. 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 foremergency services provided on September 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan has to pay for inpatient care provided to the enrollee from October 30, 2019 to
November 1, 2019.
You asked the Plan to pay for acute inpatient hospital care provided to the enrollee. You say that this claim
should be paid. The Plan denied your request. The Plan says that Medicare coverage criteria were not met.
we dismissed the case in error as a claim issue. The Plan requested a reopen and stated wedid not
review the information correctly.
Our Medical Director looked at the case file. At issue is coverage for inpatient services. The medical records
show the enrollee has benign prostatic hypertrophy and lower urinary tract symptoms. The enrollee presented
for a scheduled outpatient procedure (cystoscopy, TURP, bilateral retrograde pyelogram, bilateral
ureteroscopy, and bilateral ureteral stent insertion) on October 29, 2019. The enrollee had significant bleeding
during the procedure but overall tolerated the procedure well. On October 30, 2019 the enrollee had continued
gross hematuria, as well as fever and anemia. Continuous bladder irrigation was initiated, and IV antibiotics
were administered. Repeat labs were ordered. On October 31, 2019 the enrollee was anemic, and he reported
mild dizziness on rising and minimal shortness of breath. Transfusions of packed red blood cells were ordered.
On November 1, 2019 the enrollee's hematuria had mostly resolved, and his anemia improved. Based on this
documentation, the medical records support that it was reasonable for the admitting physician to expect that the
enrollee's medically necessary hospital stay would span two midnights at the time of admission. Medicare
coverage criteria were met.
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 inpatient care provided to the enrollee from October 30, 2019 to November 1, 2019.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says care can be provided in the current inpatient hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. You still
require acute hospital level of care services and is receiving appropriate care at the present acute care hospital.
You do not require services at the LTACH that are not available at the acute care hospital where you are
currently receiving care. There are no services available at the LTACH that you require 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 of your condition and able to be furnished safely and
effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a long term acute care hospital (LTACH).
Appeal type: Surgery
Decision: Unfavorable

e decided that the Plan does not have to pre-approvea Vertiflex Superion spacer.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has back pain and is approved for lumbar laminotomy. The requested spacer is experimental, as more research is needed to show safety and efficacy. There is no spinal instability. The services are therefore not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex Superion spacer
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe outpatient surgery services provided on July 9, 2020.You asked the Plan to waive the copay forthe services provided. You say that the provider was not able to fullyassist with your medical problem.The Plan denied your request. The Plan says the claim was processed 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 $450 copay for outpatient surgery. You have been asked to pay $322.86for the services provided. Because the amount is less than the $450 copay, you were charged the lesser amount. The services fall within the outpatient surgery 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 copay forthe outpatient surgery services provided on July 9, 2020.Your complaint regarding the outcome of the services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora chiropractic office visit received on July 16, 2020.You asked the Planto pay forthe services. You say that you would like to be reimbursed.The Plandenied your request. The Plansaysthere were multiple attempts made to gain a proof of payment.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plandoes not haveto pay fora chiropractic office visit received on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99201) radiologic examination, spine, lumbosacral (72100).
You asked the Plan to pay for the office visit and x-rays. You say that these charges could not be avoided as your previous chiropractor had died. The new chiropractor took x-ray's because they don't do adjustments blindly. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99201) radiologic examination, spine, lumbosacral (72100).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the imaging studies rendered on May 12,
2020, and July 14, 2020.
You asked the Plan to waive the copayments for these services. You say that the services are not high radiology
services so you should not be billed. 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 $160
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a free-standing facility.
Review of the file shows that you received a duplex scan of the arteries and an echocardiogram on May 12,
2020. You have been asked to pay a $160 copayment per service for these services, for a total of $320. These
services fall within the Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a free-standing facility 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 copayments
for the imaging studies rendered on May 12, 2020, and July 14, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveInjection, onabotulinumtoxina, 1 unit (J0585).You asked the Plan to pre-approveInjection, onabotulinumtoxina, 1 unit (J0585). You say that the enrollee needs Botox.The Plan denied your request. The Plan says that the enrollee does not meet the criteria rules for the requested drug.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 Injection, onabotulinumtoxina, 1 unit (J0585). Our reviewer says that the service is reasonable and necessary. Our physician reviewer found Botulinum toxin treatment is medically necessary based on the patient demonstrating blepharospasm on examination and carrying the diagnosis of blepharospasm.  According to Medicare LCD L33949, injection of botulinum toxin is a covered as a "first line treatment" for blepharospasm.  The medical records show that the patient underwent previous botulinum toxin treatment and continues to have symptomatic blepharospasm on the contralateral side of the face.  This meets LCD criteria for coverage of continued treatment with the botulinum toxin.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injection, onabotulinumtoxina, 1 unit (J0585) have been met.Therefore, we decided that the Plan has to pre-approveInjection, onabotulinumtoxina, 1 unit (J0585)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Apollo overstitch for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary to provide weight
loss while avoiding surgery. The Plan denied your request. The Plan says this 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 procedure. Our reviewer says that
the requested procedure is not considered medically reasonable and necessary in this case. Our physician
reviewer found the requested procedure has not been shown in high level published literature to be a durable
long-term treatment for weight regain after gastric bypass. Most studies reveal variable short term weight loss
with significant regain over 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 the procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve an Apollo overstitch for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinuous glucose monitor, Freestyle Libre 2 reader.You asked the Plan to pre-approvecontinuous glucose monitor. You say that the records should support the necessity of the service in dispute.The Plan denied your request. The Plan says this enrollee does not meet the Medicare criteria as they enrollee is taking long acting insulin twice per day and is not adjusting the insulin based on the readings.The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 continuous glucose monitor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet guidelines for CGM based on insulin dosing and lack of adjustment of insulin dose based on readings.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinuous glucose monitor, Freestyle Libre 2 reader.