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

We decided that the Plan does not have to waive the cost share for outpatient ankle surgery provided December 21, 2020 to December 23, 2020.
You asked the Plan to waive the cost share for outpatient ankle surgery. You say that you believe this should be considered an inpatient service. The Plan denied your request. The Plan says the cost share processed correctly, and no reimbursement is due.
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 10% coinsurance for Medicare-covered outpatient hospital services. Although your total coinsurance for outpatient ankle surgery is $1197.64 ($11,976.40 allowed amount x 10% coinsurance) you have been only asked to pay $1136.34 until the out-of-pocket maximum was reached. This service falls within the Medicare-covered outpatient hospital services benefit category because the records show you were never admitted as an inpatient. 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 cost share for outpatient ankle surgery provided December 21, 2020 to December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the member's ability to regain maximum function could be seriously jeopardized without this admission. The Plan denied your request. The Plan says that the records received do not support that the enrollee will require the special long term acute care available at an LTACH.
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. The enrollee 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 he/she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the use of this drug requires that the cancer remains, or has grown after prior fluoropyrimidine-and platinum-based chemotherapy.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee has metastatic esophageal adenocarcinoma. The record indicates that the enrollee had neoadjunctive therapy consisting of chemoradiation with carboplatin/paclitaxel. The enrollee did not undergo subsequent resection. The proposed use of the requested drug for the enrollee's clinical condition is not supported by the Medicare compendia.
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 Opdivo for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services have been deemed payable. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 provided on November 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a preemployment physical exam (99213) provided on March 2, 2021.
You asked the Plan to pay for a preemployment physical exam. You say that you believed this would be covered. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that examinations required by insurance companies, business establishments, government agencies, or other third parties are excluded from coverage. We looked at the file and Medicare rules. The record shows that the examination at issue was required by a third party. Based on this information, we decided that Medicare rules for coverage of a preemployment
physical exam have not been met. Therefore, we decided that the Plan does not have to pay for a preemployment physical exam (99213) provided on March 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurostimulator for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records sent by the doctor do not show any treatment for the required conditions.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to be treated for chronic pain syndrome and causalgia of left lower limb. However, the exams provided for review do not corroborate these assessments. The exam did not document any motor or sensory deficits. While there is a Budapest Criteria Worksheet provided (undated) that does indicate that there are subjective and objective deficits plausibly supporting the diagnosis of complex regional pain syndrome; these are not clearly demonstrated (including on the treating physician exams.) Furthermore, detailed documentation is not evident regarding trial and failure of sympathetic blocks. In addition, other plausible diagnoses (based on documentation provided) have not been fully ruled out. Therefore, the diagnosis of chronic pain syndrome is not supported and therefore, the enrollee does not have a covered indication for neurostimulator. This request is not being done as a last resort. Other treatment modalities have not been exhausted or contraindicated. Detailed documentation is not evident regarding if she is able to undergo a neurostimulator placement as she is noted to be a poor surgical candidate and why she is able to undergo one procedure and not the other. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurostimulator for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 13, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a podiatry visit provided on December 16, 2020.
You asked the Plan to waive the copayment for podiatry visit. You say that you did not have to pay anything with your previous podiatrist, and he referred you to this provider. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. The Plan also says that they have reprocessed this claim to your in-network benefit level, so you are only responsible for the in-network cost-sharing amount.
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 copayment for podiatry visit. You have been asked to pay $35 copayment for podiatry visit. Podiatry 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 a podiatry visit provided on December 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued care at a skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the continued SNF care. You say that the requested rehabilitation facility is near the enrollee's son's home. You say that the enrollee can get more benefits from rehabilitation and has been improving at physical therapy and occupational therapy while in this facility. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met.
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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued care at a skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neuropsychological testing (96132).
You asked the Plan to pre-approve the neuropsychological testing. You say that you are appealing the denial of
neuropsychological testing. The Plan denied your request. The Plan says the enrollee did not meet the Medicare
criteria for coverage.
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 neuropsychological testing. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found this enrollee is being treated for chronic pain with medical marijuana,
hydrocodone and Valium. The enrollee also experienced a steroid psychosis. It is unclear what is being
evaluated and how the treatment of pain medication regimen can enter into this enrollee's treatment. Based on
review of the records provided this enrollee has not met the requirement for neuropsychological testing based
on LCD33632 showing a reasonable expectation of improvement.
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 neuropsychological testing have not been met. Therefore, we decided that
the Plan does not have to pre-approve the neuropsychological testing (96132).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on August 28, 2020.

You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. 

In this case, the CPT Code Manual definition of code 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).

We find that CPT code 99153 is not supported in the medical record. Specifically, in the 2020 National Physician Fee Schedule Relative Value File July Release with CPT code 99153 assigned a PC/TC indicator of 3. The Medicare rule for payment of CPT code 99153 rendered August 28, 2020 has not been met. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on August 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee
from November 21, 2020, through November 22, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says the stay was not medically necessary.
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 the review indicates that the record did not show that at the time of inpatient
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including
earlier emergency department (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 to the enrollee from November 21,
2020, through November 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit provided on February 12, 2018.
You asked the Plan to pay for the annual wellness visit. You say that you only had one wellness visit in 2018. The Plan denied your request. The Plan says you also had a wellness visit on August 13, 2018 that was paid for.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit provided on February 12, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81235, 81272, 81206, 81210) provided September 21, 2020.
You asked the Plan to pay for the genetic testing. You say that the genetic testing is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Genomic Sequential Analysis Panel is covered for enrollees with advanced Non-Small Cell Lung Cancer (NSCLC) or Metastatic Colorectal Cancer (mCRC). We looked at the file and Medicare rules. The record shows the enrollee has a diagnosis of Bladder cancer. There is no record of NSCLC or mCRC. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81235, 81272, 81206, 81210) provided September 21, 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 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 surgical repair of a hip fracture after a fall. Medical conditions 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. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the injection services provided from December 7, 2020, to March 1, 2021.
You asked the Plan to waive the copays for the services provided. You say that you should not have to pay a copay to the facility. The Plan denied your request. The Plan says the claims 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 $15 copay for the total cost of Part B drugs purchased at a pharmacy, administered by a pharmacist, or administered by a health care professional.
You have been asked to pay a $15 copay on each date of service for the injections provided. The services fall within the Medicare Part B prescription drugs 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 copays for the injection services provided from December 7, 2020, to March 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgical services provided April 1,
2016.

You asked the Plan to waive the copayment for the surgical services. You say that you would like this
copayment waived. The Plan denied your request. The Plan says the copayment has 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 $200
copayment for outpatient hospital services.

You have been asked to pay a $200 copayment for the surgical services. These services fall within the
outpatient hospital 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 surgical
services provided April 1, 2016.