Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chemotherapy administration (96413) provided December 16, 2020.
You asked the Plan to pay for the chemotherapy administration. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include the most appropriate CPT code for the services performed.
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 96413 is Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance. We find that CPT code 96413 is not supported in the medical record. Specifically, Reclast (zoledronic acid) is an infusion medication used to treat Osteoporosis. The CPT code for chemotherapy administration is not appropriate to bill for this drug. Based on this information, we decided that Medicare rules for coverage of the chemotherapy administration have not been met. Therefore, we decided that the Plan does not have to pay for a chemotherapy administration (96413) provided December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for stoma care services provided October 20, 2020 to October 27, 2020.
You asked the Plan to waive the copayment for the stoma care services. You say that the services were routine stoma care and the wrong copayment was applied. The Plan denied your request. The Plan says the services included wound care and the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient hospital services.
You have been asked to pay a $150 copayment for the stoma care services. the stoma care 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 stoma care services provided October 20, 2020 to October 27, 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 need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 that you were admitted for non-surgical management of left foot fractures and knee effusion after a fall. Medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation hospital admission provided from April 23, 2020, to April 27, 2020.
You asked the Plan to waive the copayment for the inpatient rehabilitation hospital admission. You say that you received skilled nursing care, not inpatient hospital services. 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 $275 copayment per day, days 1 to 6 for at an in-network inpatient hospital. You have been asked to pay a $275 copayment for each day of the inpatient rehabilitation hospital admission. ($275 x 4 days = $1,100). The inpatient rehabilitation hospital admission falls within the "Inpatient hospital care" benefit category. The record shows the provider is credentialed as an inpatient rehabilitation hospital.
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 an inpatient rehabilitation hospital admission provided from April 23, 2020, to April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility visit provided by an out-of-network provider on December 22, 2020.

You asked the Plan to pay for the nursing facility visit. You say that the provider is the attending doctor at the facility and the primary care office will not give referrals. You say that this is out of their control and the claim should be processed. The Plan denied your request. The Plan says authorization must be requested and approved prior to rendering the service.

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 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 nursing facility visit provided by an out-of-network provider on December 22, 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 prophylaxis (D1110) received December 22, 2020 from an out-of-network provider.
You asked the Plan to pay for the dental services. You say that having your teeth cleaned is medically necessary. The Plan denied your request. The Plan says services performed by an out-of-network provider are not covered because your healthcare plan does not have out-of-network benefits.
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. You received these services from an out-of-network provider. Your Plan does not have out-of-network benefits. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), and the prophylaxis (D1110) received December 22, 2020 from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the steroid injection provided on November 10, 2020.
You asked the Plan to waive the copayment for the steroid injection. You say that you pay $45 for a specialist and you are being charged $260 just for putting in the injection. You say that the injection was covered but not putting the injection in. 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 $260 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $260 copayment for the steroid injection. The steroid injection falls within the "Outpatient Surgery and Other Medical 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 steroid injection provided on November 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has metastatic hepatocellular carcinoma. Tecentriq (atezoliumab) in combination with bevacizumab is FDA approved for 1st line treatment of advanced hepatocellular carcinoma. The enrollee has had at least two prior lines of systemic therapy including prior immunotherapy with pembrolizumab. The service is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve spinal facet joint injections. We decided that the Plan does not have to pre-approve confirmatory second set of blocks at the third level.
You asked the Plan to pre-approve spinal facet joint injections. You say that you would like the plan to reconsider their denial. The Plan says that the requested services are not medically necessary.
We decided that the Plan has to pre-approve confirmatory second set of blocks at two levels.
The Plan follows Medicare rules. Medicare rules say that branch blocks are covered for certain indications. 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 facet joint injections. Our reviewer says that the documentation Our physician reviewer found the enrollee has chronic neck pain and headache. The enrollee had a three-level diagnostic bilateral medial branch blocks which produced 80% pain relief for the duration of the local anesthetic. The first set was successful at demonstrating the pain generator. Therefore, the enrollee meets criteria for the requested 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 spinal facet joint injections have been met. Therefore, we decided that the Plan has to pre-approve confirmatory second set of blocks at two levels.
We also decided that the Plan does not have to pre-approve confirmatory second set of blocks at the third level.
The Plan follows Medicare rules. Medicare rules say that criteria limits the levels to two at a session. 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 confirmatory second set of blocks at the third level. Our reviewer says that the documentation Our physician reviewer found the enrollee had a three-level diagnostic Bilateral Medial Branch Blocks which produced 80% pain relief for the duration of the local anesthetic. The utilization criteria, however, limits the levels to two at a session and therefore, only two levels can be blocked and those would be considered 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 confirmatory second set of blocks at the third level have not been met. Therefore, we decided that the Plan does not have to pre-approve confirmatory second set of blocks at the third level.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services, extraspinal manipulations, and an X-Ray examination provided by a chiropractor from August 17, 2020, to September 23, 2020.
You asked the Plan to pay for chiropractic services. You say that you were never informed that these services would not be covered, so you should not be responsible for paying for them. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for physical therapy services, extraspinal manipulations, and an X-Ray examination provided by a chiropractor from August 17, 2020, to September 23, 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 enrollee will need more frequent physician visits, frequent monitoring, and interventions. The Plan denied your request. The Plan says the records do not support the ability to tolerate an intensive rehab therapy program.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for cardiac catheterization, and coronary artery bypass grafting. His medical conditions are stable. There are no complex nursing needs. There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. He does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on
November 24, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 23, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for diagnostic radiology services provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Shingrix (shingles vaccine) for the enrollee.
You asked the Plan to pre-approve the vaccine. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pre-approve Shingrix (shingles vaccine) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a special knee, foot, ankle and manual lock (L5812, L5845, L5850, L5925).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the objective data in the records from your provider (visit note of 10/22/2020 documenting a left knee contracture and a desire for the prosthesis for aesthetic reasons), a more basic K1 prosthesis appears to be the appropriate type prosthesis for this 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a special knee, foot, ankle and manual lock (L5812, L5845, L5850, L5925).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services (HCPCS G8753, HCPCS G8754) provided to the enrollee on August 10, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the codes are billed incorrectly.
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 the denied codes is: HCPCS G8753: Most recent systolic blood pressure >= 140 mmhg HCPCS G8754: Most recent diastolic blood pressure < 90 mmhg
We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our codingreviewer found per the Medicare Physicians Fee Schedule, HCPCS G8753 and G8754 have status code indicator "M - Measurement codes, Used for reporting purposes only" and would not be covered separately. We looked at this coder'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 pay for the medical services (HCPCS G8753, HCPCS G8754) provided to the enrollee on August 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on September 14, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford the copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $275 copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $275 for these services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services provided on September 14, 2020.