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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 enrollee was admitted for surgical treatment of a hip fracture after a fall and was discharged home with home health physical therapy. The enrollee's medical problems are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care need can be met 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 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Jelmyto.
You asked the Plan to pre-approve Jelmyto. You say that the requested Jelmyto is medically necessary. The Plan denied your request. The Plan says that the requested Jelmyto is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Jelmyto. Our reviewer says that the requested Jelmyto is medically necessary. Our physician reviewer found the enrollee is diagnosed with noninvasive low-grade upper tract urothelial cancer. The request is for Jelmyto. Drug Dex, a Medicare approved compendia states the Food and Drug Administration has provided an orphan drug designation for the requested drug for treatment of upper tract urothelial cell cancers. The presence of the citation within DrugDex constitutes a non-FDA approved medically accepted indication. In this case, the enrollee has a high-grade upper tract urothelial carcinoma. The elements of the non-FDA approved medically accepted indication are satisfied. The requested service is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Jelmyto have been met. Therefore, we decided that the Plan has to pre-approve Jelmyto.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a PET/CT scan provided to the enrollee on November 22, 2020.

You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The Plan says claims must be billed with an appropriate diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 pay for the scan. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found PET scans are nationally non-covered for initial staging of axillary nodes. It is covered for metastatic disease. The request cannot be substantiated in the medical records.

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 scan have not been met. Therefore, we decided that the Plan does not have to pay for a PET/CT scan provided to the enrollee on November 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on September 15, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 services provided to the enrollee by an out-of-network
provider on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92310, 92015, S0621) provided October 15, 2020.
You asked the Plan to pay for the eye exam. You say that the service should be covered. The Plan denied your request. The Plan says the eye exam was obtained out-of-network and therefore the enrollee is responsible for any amount over $75.
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 one eye exam annually. When obtained out-of-network, the enrollee is responsible for any amount over $75. We looked at the file and the Plan's rules. The eye exam was obtained out-of-network. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. The plan is only responsible for $75 towards the eye exam. Therefore, we decided that the Plan does not have to pay for an eye exam (92310, 92015, S0621) provided October 15, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department visit for the evaluation and management of a patient (99285) provided September 29, 2020.

You asked the Plan to pay for the emergency visit. You say that you are requesting review of the attached emergency department record, reprocess and approve the claim at the appropriate reimbursement rate for the E/M code billed. The Plan denied your request. The Plan says the documentation does not support the E/M level as reported on the claim. The plan has paid for CPT 99284.

The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided. 

In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status):

1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity.

In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function. 

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 the emergency visit Our reviewer says that the records do not support the Medicare criteria for 99285. Our reviewer found the emergency room report supports a comprehensive history, and medical decision making of moderate complexity for ECG, and laboratory testing. Per CPT guidelines, documentation must meet 3 out of 3 key components to report the level of service. The documentation supports CPT 99284.

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 emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for emergency department visit for the evaluation and management of a patient (99285) provided September 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient detoxification services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee has normal vital signs and withdrawal symptoms.

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 requested services. Our physician reviewer found that the enrollee has a history of opiate use disorder, severe, with worsening symptoms, without perceptual hallucinations, stimulant use disorder, moderate, history of bipolar disorder, generalized anxiety disorder. The records did not show that the enrollee's condition requires inpatient services during detox. The requested inpatient services were not medically reasonable and 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient detoxification services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostate specific antigen (PSA) testing rendered on December 16, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that screening prostate specific antigen tests are covered at a frequency of once every 12 months. We looked at the file and Medicare rules. The file shows that you had a PSA test on January 20, 2020 that the Plan covered. The PSA test on December 16, 2020 was performed less than 12 months from your previously covered exam. Therefore, we decided that the Plan does not have to pay for the prostate specific antigen (PSA) testing rendered on December 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 15, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the
laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation
and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting
where the beneficiary receives the face to-face service.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the laboratory services have not been met. Specifically, the claim was submitted with a laboratory
place of service code, but the record indicates that the member's face-to-face service was rendered in an office
setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April
15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for radiology services provided by a participating provider on September 21, 2020.

You asked the Plan to waive the co-payment for radiology services. You say that you do not agree with this. The Plan denied your request. The Plan says the correct co-payment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 co-payment for outpatient diagnostic tests/in-network/basic radiology/specialist.

You have been asked to pay a $35 co-payment for radiology services. Radiology services fall within the outpatient diagnostic tests/in-network/basic radiology/specialist 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 co-payment for radiology services provided by a participating provider on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture provided on October 27, 2020.

You asked the Plan to pay for the mandibular partial denture. You say that you would like this service covered. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective September 21, 2015, to September 21, 2021.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture provided on October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ostomy supplies (A4424) provided on October 2, 2020.

You asked the Plan to pay for the ostomy supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says there was no prior authorization for the out-of-network supplier.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for ostomy supplies (A4424) provided on October 2, 2020.
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 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. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on April 21, 2021 with a stroke. The physical therapy and occupational therapy notes dated May 5, 2021 state she needs stand-by assist to stand up and sit. She needs minimal assist to walk five feet with a rolling walker. She does not require the intensity of services in an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #19.

You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says the requested properly labeled and request x-ray from different angles was not received. The Plan also says that the x-ray that was received does not show that the enrollee met the requirement for a crown at this time.

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. The Plan covers the crown when the services are medically necessary and reasonable.

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 crown. Our reviewer says that the documentation provided does not meet the criteria for coverage for a crown restoration for tooth #19. Our physician reviewer found the documentation provided did not contain a radiograph of tooth #19. As noted in the criteria for coverage, a radiograph is required to determine the need for a crown restoration. Our reviewer also found that there was no narrative indicating why a crown restoration was required.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L2397, L1833) provided October 2, 2020.
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied
your request. The Plan says the documentation does not support the services 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 codes L2397 & L1833 are not supported in the medical record. Specifically, the plan has
attested that there is no record of a claim for an in-person or telephonic visit by the ordering physician for this
enrollee. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been
met. Therefore, we decided that the Plan does not have to pay for orthoses (L2397, L1833) provided October 2,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99238) provided December 17, 2020.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the billed service has a column I/column II relationship with another
service 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, we have confirmed that code 99238
has a column I/column II relationship with code 99239 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 physician services (99238) provided December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81400, 81406, 81408, 81401) provided
November 23, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the claim was not filed 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 81400, 81406, 81408, 81401 are not supported in the medical record. Specifically, per
the National Correct Coding Initiative Coding Policy Manual for Medicare Services the services billed should
be billed using CPT code 81479. This service cannot be billed with unbundled codes. Based on this
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we
decided that the Plan does not have to pay for lab services (81400, 81406, 81408, 81401) provided November
23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second transport chair.

You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation indicates you already have a transport chair.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 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 chair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the special transport chair is not necessary. You already currently have a transport chair. There are no extenuating medical reasons that require a duplicate transport chair. 

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 chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a second transport chair.