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

We decided that the Plan does not have to waive the copayment for the diagnostic laryngoscopy provided on March 9, 2021.
You asked the Plan to waive the copayment for the diagnostic laryngoscopy. You say that you have had this procedure multiple times in the past and did have to pay this amount. The Plan denied your request. The Plan says you have been asked to pay the correct 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 a $250 copayment per visit for Medicare-covered in-network outpatient surgery.
You have been asked to pay a $250 copayment for the diagnostic laryngoscopy. The diagnostic laryngoscopy
falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers" benefit category. The record shows the allowed amount is $253.91 which means you are
responsible for the full $250 copayment.
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 diagnostic laryngoscopy provided on March 9, 2021.
Please note, our decision is only regarding the March 9, 2021 date of service. Please contact the Plan directly
for any questions regarding previous years' billing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture with limited field of view - less than one whole jaw (D0364), limited oral evaluation - problem focused (D0140), panoramic radiographic image (D0330), amalgam - one surface, primary or permanent (D2140), and intraoral - periapical first radiographic image (D0220) provided June 17, 2020.
You asked the Plan to pay for the cone beam CT scan, limited oral exam, panoramic x-rays, filling and intraoral x-rays. You say that you were unaware that the dentist had opted out of Medicare and the services would not be covered. The Plan denied your request. The Plan says the services are not covered because the provider has opted out of Medicare.
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 cone beam CT scan, limited oral exam, panoramic x-rays, filling and intraoral x-rays when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Medicare. We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the cone beam CT scan, limited oral exam, panoramic x-rays, filling and intraoral x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture with limited field of view - less than one whole jaw (D0364), limited oral evaluation - problem focused (D0140), panoramic radiographic image (D0330), amalgam - one surface, primary or permanent (D2140), and intraoral - periapical first radiographic image (D0220) provided June 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment from $125 to $95 for the transthoracic echocardiography (93306) provided on August 5, 2020.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free standing facility (such as a radiology center or medical clinic).
You have been asked to pay a $125 copayment for the Medicare-covered radiological diagnostic service
provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to adjust the copayment from $125 to $95 for the transthoracic
echocardiography (93306) provided on August 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital admission.
You asked the Plan to pre-approve acute inpatient hospital admission. 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 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 admission. 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 enrollee is undergoing an elective procedure. He is medically stable and has
been provided medical clearance to undergo this elective procedure. There is no documentation provided to
support the expectation the enrollee will require a greater than two midnight stay.
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 admission have not been met. Specifically, 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 ED and/or observation care) would span two midnights.
Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have [e.g., to pay for ... to provide ... to waive the copayment for ... ] the stair
lift rendered on November 16, 2020.
You asked the Plan [e.g., to pay for ... to provide ... to waive the copayment for ... ] these services. You say that
you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have [e.g., to pay for ... to provide ... to waive the copayment for ... ] the stair lift
rendered on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and the intraoral - periapical each additional radiographic image (D0230 x 4) received February 10, 2021. You asked the Plan to pay for the intraoral periapical images. You say that you cannot afford the requested services and would like the Plan to cover them. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit. 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 intraoral - periapical first radiographic image (D0220) and the intraoral - periapical each additional radiographic image (D0230 x 4) received February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on January 4, 2021 by an out of
network (OON) provider.
You asked the Plan to pay for specialist services. You say that you would like the Plan to pay for this. The Plan
denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician. The Plan says that there are in-network providers available for these services.
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/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to
pay for these items/services. Therefore, we decided that the Plan does not have to pay for specialist services
provided on January 4, 2021 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say payment for inpatient hospital services in made of the basis of a DRG (diagnosis related group). Hospitals must provide proper information about the patient (i.e., age, sex, discharge status, principal and secondary diagnoses, and procedures) in order for the correct DRG to be assigned. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 3, Section 20.2.1. The rule say that the circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care." For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring. The UHDDS item #11-b defines Other Diagnoses as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded." You can find this information in the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines for Coding and Reporting, Sections II and III.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
January 21, 2021.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. 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 subsequent nursing facility care provided on January 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the excision of a benign lesion provided on January 7, 2021. You asked the Plan to waive the copayment for the excision of a benign lesion. You say that you have never been charged such a high copayment to have something shaved off and feel that it should not have been coded as outpatient surgery. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You received the excision of a benign lesion at an outpatient hospital facility on January 7, 2021. The excision of a benign lesion is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $243.55, which is less than the $275 copayment. You have been asked to pay $243.55 for the excision of a benign lesion. The excision of a benign lesion falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 excision of a benign lesion provided on January 7, 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 you have reached the maximum benefit for home physical therapy and you need intensive therapy provider by an inpatient rehab. 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 have a past medical history of right above the knee amputation in April 2020 and are living at home with difficulty with ambulation. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve autograft for spine surgery only (20936), arthrodesis, posterior interbody technique, single interspace; lumbar (22630), posterior non-segmental instrumentation (22840), and insertion of an interbody biomechanical device(s) with integral anterior instrumentation for device anchoring (22853).
You asked the Plan to pre-approve spinal surgery. You say that the services are medically necessary. The Plan denied your request. The Plan says there is no documentation of conservative care, based on the clinical information provided, the requested service/procedure 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 spinal surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation lacks fundamental detail as to conservative measures that have been tried. This needs to be documented before any surgical intervention. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery have not been met. Specifically, there is insufficient documentation of prior treatments for this enrollee. Therefore, we decided that the Plan does not have to pre-approve autograft for spine surgery only (20936), arthrodesis, posterior interbody technique, single interspace; lumbar (22630), posterior non-segmental instrumentation (22840), and insertion of an interbody biomechanical device(s) with integral anterior instrumentation for device anchoring (22853).
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 therapists and primary care providers highly recommend rehab for the best level of care the enrollee needs and requires. 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for. syncope and hemorrhagic shock after a fall two (2) days earlier. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does 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 this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for addition, endoskeletal system, above knee or hip disarticulation, alignable system (CPT code L5920), for the enrollee.
You asked the Plan to pay for the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says the service is not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The enrollee's current prosthetic socket (A108060240), delivered December 2020, includes L5920, Addition, endoskeletal system, above knee, alignable system. Notes do not show that L5920 is damaged beyond repair and cannot be re-used for approved socket. While notes from the prosthetist (vendor) state include L5920, the physician office visit notes do not corroborate the vendor's notes showing need to replace L5920. Per Medicare guidelines, "Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and necessary." While the signed physician order includes L5920, per Medicare rules, "A prescription is not considered to be part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record." The notes do not show why enrollee's current L5920 Alignable System cannot be used for approved replacement socket. Therefore, we decided that the Plan does not have to pay for addition, endoskeletal system, above knee or hip disarticulation, alignable system (CPT code L5920), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra solution prefilled syringes. You asked the Plan to pre-approve Fasenra. You say that this medication is medically necessary for the enrollee's treatment. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Fasenra solution prefilled syringes.