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

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0428, A0425) received June 10, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you have had financial difficulty in the last year and would appreciate the waiver of the copayment. The Plan denied your request. The Plan says the correct cost share applied to the claim.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that you must pay a $265 copayment for Ambulance Services. The enrollee has been asked to pay a $265 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when she enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation (A0428, A0425) received June 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botulinum Toxins (Botox) injections.
You asked the Plan to pre-approve Botox injections. You say that you feel these injections are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested injections.
The Plan follows Medicare rules. Medicare rules say that Botox injections are only 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 Botox injections. Our reviewer says that the documentation does not support that the requested Botox injections are medically reasonable or necessary. Our physician reviewer found you have a past medical history of hypertension, hyperlipidemia and piriformis syndrome. Piriformis syndrome is not a diagnosis listed in the LCD or in the major drug compendia for which Botox injections are indicated. Therefore, you do not meet 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 Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botulinum Toxins (Botox) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive to waive the $35 copayment for specialist services provided on November 5, 2020.
You asked the Plan to waive this copayment. You say that this was follow-up after an out of network emergency which should be covered. The Plan denied your request. The Plan says this claim was paid, and you are only being charged the in-network specialist copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $35 for specialist services. 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 to waive the $35 copayment charged for specialist services provided on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and an extraction (D7210).
You asked the Plan to pre-approve a comprehensive oral evaluation, and an extraction. You say that the services are necessary. The Plan denied your request. The Plan says the services at issue are not covered unless they are performed by a participating general dentist. Dental services performed by an oral surgeon are not covered.
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 a comprehensive oral evaluation, and an extraction have not been met. Specifically, the services at issue are not covered unless they are performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and an extraction (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from October 7, 2020, to October 12, 2020.
You asked the Plan to pay for out of network services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 out of network physician services provided from October 7, 2020, to October 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from December 6, 2020, to January 4, 2021.

You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from December 6, 2020, to January 4, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Trazimera 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 this drug is investigational in all cases.

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 periambullary cancers can be treated like small bowel, exocrine pancreas, or cholangiocarcnoma. HER2 targeted therapy has been effective in some cholangiocarcinomas that express HER2. Given this it would not be unreasonable to add trastuzumab to FOLFIRI as subsequent line therapy for systemic disease. The service is reasonable and 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve Trazimera 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on September 08, 2020 and billed under code 99153.

You asked the Plan to pay for code 99153. You say that this claim should be paid. The Plan denied your request. The Plan says this code cannot be paid as billed due to an error with the billing of a technical component.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid as billed due to an error with a technical billing issue. Medicare does not allow payment for the technical component (TC) of radiology services furnished to hospital patients.

The records show the enrollee was in an inpatient facility setting from December 30, 2019 to January 05, 2020; therefore, this claim cannot be paid as billed. The Plan states a corrected claim would be accepted. Therefore, we decided that the Plan does not have to pay for code 99153 provided on September 08, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Pride Zero four-wheel scooter (K0899) and a cell
phone holder (K0108).

You asked the Plan to pre-approve a Pride Zero four-wheel scooter and a cell phone holder. You say that you
need this scooter because it is larger and you are in it for long periods of time. The Plan denied your request.
The Plan says these items are not covered.

The Plan must follow Medicare rules. The rules say that a power operated vehicle (POV) or power wheelchair
(PWC) which has not been reviewed by the Pricing, Data Analysis, and Coding (PDAC) contractor or which
has been reviewed by the PDAC and found not to meet the definition of a specific POV/PWC will be denied as
not reasonable and necessary and should be coded as K0899. The rules also say that for equipment to be
covered, it must primarily serve a medical purpose.

The specific requested power scooter is coded as K0899, meaning it has been found not to meet the definition
of a specific POV/PWC and is considered not reasonable and necessary. The cell phone holder 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 to pre-approve a Pride Zero four-wheel scooter (K0899) and a cell phone holder (K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided by a participating provider on November 9, 2020, to December 21, 2020.

You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you already paid this. The Plan denied your request. The Plan says the correct copayment has been 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 $20 copayment for outpatient rehabilitation services/in-network. 

You have been asked to pay a $20 copayment for outpatient rehabilitation services. Outpatient rehabilitation service falls within the outpatient rehabilitation services/in-network 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 outpatient rehabilitation services provided by a participating provider on November 9, 2020, to December 21, 2020.

We note your complaint about having already paid your copayment. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, continued in the long-term care facility, or at the home with home health care services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT, heart.

You asked the Plan to pre-approve a computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium (75571). You say that you want to see if you need medication for high cholesterol. The Plan denied your request. 

The Plan says that the requested type of testing is not supported without signs and or symptoms of heart disease.
The Plan must follow Medicare rules. Medicare rules say that CT 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 pre-approve a computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium (75571). Our reviewer says that the service is reasonable and medically necessary. Our physician reviewer found this type of screening would be appropriate in this enrollee to assist with decisions related to decreasing risk and managing cholesterol levels. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium (75571) have been met. Therefore, we decided that the Plan has to pre-approve a CT, heart.

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: Favorable

We decided that the Plan has to pre-approve high dose rate surface Brachytherapy.

You asked the Plan to pre-approve these services. You say that the enrollee is bedbound and needs mobile treatment. The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has scalp vertex melanoma. The use of surface Brachytherapy for skin cancer is not a new modality and is considered the standard of care by several American medical societies. The requested services are reasonable and medically necessary for the enrollee at this time.

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 been met. Therefore, we decided that the Plan has to pre-approve high dose rate surface Brachytherapy.

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: 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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from August 23, 2019 to September 5, 2019.
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 DRG and diagnosis are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 682 and diagnosis code E87.1 (hypo-osmolality and hyponatremia).
We looked at the file and Medicare rules. The records do not support the billing of E87.1 as a primary diagnosis. The records show that the enrollee presented with nausea, vomiting, and leg cramping with end-stage renal disease as a known chronic condition. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from August 23, 2019 to September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (CPT 99308) provided to the enrollee on November 25, 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 this procedure would not be allowed even if the appropriate modifier was present.
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 99308 is "subsequent nursing facility care for the evaluation and management of a patient." 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 coding reviewer found two evaluation and management codes were billed for the same date of service for two different providers with same specialty in same group. In this case, only one evaluation and management code should be reported. 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 subsequent nursing facility care (CPT 99308) provided to the enrollee on November 25, 2020.