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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The
Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
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 the enrollee has been in the hospital for a week and continues to improve with
medications and respiratory support. The enrollee does not require services at the LTACH that are not available
at the acute care hospital where currently receiving 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 LTACH services have not been met. Specifically, medically necessary services are being obtained at their current level of care. This means admission into a LTACH is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically necessary. The Plan denied your request. The Plan says the criteria for inpatient care have not been met.

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 pre-approve 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 that the enrollee is undergoing a planned elective left knee surgery. She is medically stable. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department 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 pre-approve acute inpatient hospital care.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from January 20, 2021, through February 18, 2021.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says when enrolled in a Medicare-certified hospice program, hospice services and your Part A and Part B services related to your terminal prognosis are paid for by Original Medicare, not the Plan.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for SNF services provided from January 20, 2021, through February 18, 2021.
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 the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient
does require physical therapy and occupational therapy services but based on the medical records provided the
patient does not require an intensive inpatient rehabilitation therapy program. There is no documentation that
the patient requires the intensive rehabilitation therapy program provided in an IRF. Care at the skilled nursing
facility level appears to be appropriate in this case.

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: Favorable

We decided that the Plan has to pre-approve Aduhelm intravenous solution 100mg/1ml 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 that Medicare has not yet determined if this drug will be covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the
requested drug is medically reasonable and necessary. Our physician reviewer found the documentation
supports that the enrollee in this case has mild cognitive impairment due to Alzheimer's disease, which is an
FDA-approved indication for the drug. By law, Medicare covers approved drugs unless an action is taken to
exclude coverage. The documentation supports that this drug would be safe and effective for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the drug have been met. Therefore, we decided that the Plan has to pre-approve
Aduhelm intravenous solution 100mg/1ml for the enrollee.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on February 19, 2021.

You asked the Plan to waive the copayment for these services. You say that you were not aware the cost would be higher at an outpatient hospital. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for same-day outpatient surgery in an outpatient hospital facility. 

Review of the file shows that you received a cystoscopy on February 19, 2021. You have been asked to pay a $350 copayment for these services. These services fall within the same-day outpatient surgery in an outpatient hospital 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 copayment for the outpatient surgical services rendered on February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for IV tubing extension set (S1015) and infection control
supplies (S8301), provided on January 18, 2021.

You asked the Plan to pay for IV tubing extension set and infection control supplies. You say that the items are
medically necessary. The Plan denied your request. The Plan says these codes are not valid codes for Medicare
purposes.

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 S1015 and S8301 are not supported in the record. Specifically These codes are not valid for Medicare Purposes. Based on this information, we decided that Medicare rules for coverage of IV tubing extension set and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for IV tubing extension set (S1015) and infection control supplies (S8301), provided on January 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on February 21, 2020.

You asked the Plan to pay for the chest x-ray (71045). You say that the provider performed the services and
should be paid accordingly. The Plan denied your request. The Plan says the claim was untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the chest x-ray (71045) was not filed until April 2, 2021. This means that
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for the chest x-ray provided on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist services provided on February 18, 2021.

You asked the Plan to waive the copay for the services provided. You say that you should not have to pay for the claim. 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 $50 copay for specialist visits. 

The file shows that you were seen for an audiology visit. You have been asked to pay a $50 copay for the services provided. the services provided falls within the physician 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 copay for the specialist services provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on March 10, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you already paid $200 for the cataract surgery and the follow up appointment should be included. You say that copayment should not be a separate specialist visit. The Plan denied your request. The Plan says the copayment 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 $35 copayment for each in-person specialist visit.
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the office visit was outside of the 90-day covered global period. 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 office visit provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided on November 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services do not meet the coverage requirements.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the records do not show that the acupuncture services were provided by a physician or by auxiliary personnel under the supervision of a physician. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided on November 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided from May 4, 2020, to May 9, 2020.

You asked the Plan to pay for critical care services. You say that these services are supported in the records. The Plan denied your request. The Plan says these services are not documented.

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 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 critical care services. Our reviewer says that this code is not supported. Our physician reviewer found the medical records submitted do not include sufficient documentation to validate that the billed critical care services were performed on the dates of service at issue. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided from May 4, 2020, to May 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the chest x-ray rendered on November 18, 2020.
You asked the Plan to waive the deductible for these services. You say that you already paid a copayment for these services. The Plan denied your request. The Plan says the deductible was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the basic imaging service benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on November 18, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the chest x-ray rendered on November 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 1, 2021.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital observation (G0378) provided on February 5, 2021.
You asked the Plan to waive the copayment for hospital observation. You say that you were told that you would pay $75. You disagree with the charges. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for outpatient hospital observation. You have been asked to pay a $125 copayment for hospital observation. The service at issue falls within the outpatient hospital observation 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 hospital observation (G0378) provided on February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 3, 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 procedure codes 26952, 26746, 64702, and 26735 are not supported.

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 26952 is amputation, finger or thumb, primary or
secondary, any joint or phalanx, single, including neurectomies; with local advancement flaps (V-Y, hood).
The definition of code 26746 is open treatment of articular fracture, involving metacarpophalangeal or
interphalangeal joint, includes internal fixation, when performed, each. The definition of code 64702 is
neuroplasty; digital, 1 or both, same digit. The definition of code 26735 is open treatment of phalangeal shaft
fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed, each.

We find that CPT codes 26952, 26746, 64702, and 26735 are not supported in the medical record. Specifically,
there is no documentation of a primary or secondary single amputation of the finger/thumb to support code
26952. There is no documentation of an open treatment of articular fracture to support code 26746. There is no
documentation of neuroplasty of one or both digital nerves to support code 64702. There is no documentation
of open treatment of phalangeal shaft fracture of each of the proximal or middle phalanx of the finger or thumb
to support code 26735.

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 pay for the surgical services rendered on October 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CGM (CPT code K0553).

You asked the Plan to pre-approve the CGM. You say that you went a month without any medication, so your
blood sugar was fluctuating. The Plan denied your request. The Plan says the Medicare rules have not been
met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. You do not measure your blood sugar at least four times a day using
a blood glucose monitor. You do not require insulin shots at least three times a day or you use a continuous
subcutaneous insulin infusion pump. You do not require frequent changes to your insulin dose. Based on this
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we
decided that the Plan does not have to pre-approve CGM (CPT code K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for fillings (D2391, D2392) provided on
April 8, 2021.

You asked the Plan to pay an additional amount for fillings. You say that one cavity per year should be
covered. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate for a
filling (D2391) therefore no additional payment can be made. A filling (D2392) is a covered benefit, but you
have exceeded the frequency limit of one every calendar year.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of fillings have not been met. Specifically, the allowed amount of code D2391 for an out-of-network
provider was paid by the plan.

Additionally, the record shows that you had exceeded the frequency limit for code D2392. Therefore, we
decided that the Plan does not have to pay an additional amount for fillings (D2391, D2392) provided on April
8, 2021.