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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example: skilled nursing facility,
home with home health services or home with outpatient therapy.
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 weakness and rhabdomyolysis after a fall. Medical problems 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. 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 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 clinical documentation provided supports the need for LTACH care. The Plan denied your request. The Plan says it is not medically necessary for the enrollee to be in an LTACH in place of an acute care hospital.
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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory tests provided on January 17, 2021.
You asked the Plan to pay for the laboratory tests. You say that the medical records should be reviewed and the claim should be processed for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
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 the laboratory tests provided on January 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on December 14, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for an outpatient surgery. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 an outpatient surgery provided on December 14, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for anti-reflective lenses (V2750), ultraviolet lenses (V2755) and polycarbonate lenses (V2784) provided on February 23, 2021.
You asked the Plan to pay for anti-reflective lenses, ultraviolet lenses and polycarbonate lenses. You say that the additional lenses are required because your vision is suffering, and you have a detached retina. You also say that heading into cataract surgery, all the above lenses are required for your vision. The Plan denied your request. The Plan says that the lenses are covered when they are medically necessary for you and the medical necessity is documented by the provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you are eligible for an allowance of $100 every 12 months for elective contacts, one pair of standard lenses, one frame or one complete pair of eyeglasses. The Plan covers these services when they are medically necessary. We looked at the file and the Plan's rules. The records show you are eligible for an allowance of $100, every 12 months, for the purchase of frames. The records also show that you exhausted your $100 allowed benefit on February 23, 2021. Based on this information, we decided that the Plan's rules for coverage of anti-reflective lenses, ultraviolet lenses and polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to pay for anti-reflective lenses (V2750), ultraviolet lenses (V2755) and polycarbonate lenses (V2784) provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment amount for a medical eye exam (92014) provided on March 9, 2021.
You asked the Plan to reduce the copayment amount for a medical eye exam. You say that you had a routine eye exam and should pay a $15 copayment. You also say that you were not treated for any condition of the eye. The Plan denied your request. The Plan says you received services to address a medical condition.
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 you pay a $15 copayment for one annual routine eye exam. If you receive services that address a medical condition during the same office visit, you pay a $45 specialist office visit copayment.
You have been asked to pay a $45 copayment for a medical eye exam. The records show that you were treated for a posterior vitreous detachment and a glaucoma suspect of both eyes. The EOC confirms that $45 is the required copayment for this service. A medical eye exam falls within the vision care 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 reduce the copayment amount for a medical eye exam (92014) provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the Esophagogastroduodenoscopy, with biopsy (43239) provided on December 1, 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 $300 copayment for Medicare-covered outpatient surgery at an ambulatory surgical center.
You have been asked to pay a $300 copayment for the Medicare-care covered outpatient surgery provided at an ambulatory surgical center. 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 for the Esophagogastroduodenoscopy, with biopsy (43239) provided on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided December 14, 2020.

You asked the Plan to pay for the hospital discharge day management. You say that resubmitting the claim with the medical record attached. Please review for payment. The Plan denied your request. The Plan says the records do not support the billed service.

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 99239 is hospital discharge day management of more than 30 minutes.

We find that CPT code 99239 is not supported in the medical record. Specifically, the discharge summary submitted does not support hospital discharge day management of more than 30 minutes. A documented duration time of 31 minutes or more is required. The plan had made multiple attempts to obtain additional information form the provider without success. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided December 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection and copayment for radiology services provided by a participating provider on May 4, 2021.

You asked the Plan to waive the coinsurance for an injection and copayment for radiology services. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance and copayment have 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% coinsurance for Medicare Part B prescription drugs/in-network and a $175 copayment for outpatient diagnostic tests/diagnostic radiology/in-network.

You have been asked to pay a 20% coinsurance of the allowed amount for an injection and a $175 copayment for radiology services. The total allowed amount for the injection is $8.80. The amount you are being asked to pay for the injection is $1.76 ($8.80 x 20% = $1.76). The total amount you are being asked to pay is $176.76 ($1.76 + $175 = $176.76). An injection falls within the Medicare Part B prescription drugs/in-network benefit category and radiology services falls within the outpatient diagnostic tests/diagnostic radiology/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 coinsurance for an injection and copayment for radiology services provided by a participating provider on May 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the knee orthosis, immobilizer (L1830) provided on March 10, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the item 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 20% coinsurance for Medicare-covered durable medical equipment and related supplies. You have been asked to pay $16.04 (Plan allowed amount of $80.20 x 20% coinsurance) for the Medicare-covered durable medical equipment 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 waive the coinsurance for the knee orthosis, immobilizer (L1830) provided on March 10, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided on July 27, 2020.
You asked the Plan to pay for the laboratory test. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
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 the laboratory test provided on July 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy administration services coded 96401 provided on February 26, 2021.
You asked the Plan to pay for the chemotherapy administration services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 96401 is chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic.
We find that CPT code 96401 is not supported in the medical record. Specifically, the documentation supports that the services rendered were a subcutaneous injection of Fasenra. There is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the chemotherapy administration services have not been met. Therefore, we decided that the Plan does not have to pay for the chemotherapy administration services coded 96401 provided on February 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued care in the acute inpatient rehabilitation facility is appropriate (and endorsed by the health plan) until you are stable to transfer to home with home health 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a colonoscopy.

You asked the Plan to pre-approve colonoscopy. You say that the enrollee requires a follow-up colonoscopy this year due to having recurring polyps in the past. The Plan denied your request. The Plan says that the enrollee does not meet the criteria for 5-year colonoscopy surveillance and a colonoscopy is not warranted at this time.

The Plan follows Medicare rules. Medicare rules state that screening colonoscopies may be covered at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer.

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 colonoscopy. Our reviewer says that the enrollee meets the Medicare criteria for the requested colonoscopy. Our physician reviewer found the enrollee has a history of mixed tubulovillous adenoma, hyperplastic polyp, and adenomatous polyp. A tubular adenoma was removed in 2016. It is determined that the enrollee is at high risk for developing colorectal cancer given his personal history of adenomatous polyps. At least 23 months have passed following the month in which the last screening colonoscopy was performed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of colonoscopy have been met. Therefore, we decided that the Plan has to pre-approve a colonoscopy.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 8, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization is not obtained by the member's primary care physician.

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 lab work provided on September 8, 2020 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services (78815, A9552, 82947, 82565) provided on February 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient services. You say that please review the medical documentation and reprocess the claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the outpatient hospital services (78815, A9552, 82947, 82565) provided on February 24, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation (D9310), core buildup (D2950),
prefabricated post and core (D2954), crowns (D6750), pontics (D6240), periodontal maintenance (D4910) and
periodontal scaling and root planing (D4341).
You asked the Plan to pre-approve the consultation, core buildup, prefabricated post and core, crowns, pontics,
periodontal maintenance and periodontal scaling and root planing. You say that you need these procedures and
want something to be done. The Plan denied your request. The Plan says the services are not covered 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. Therefore, we decided that the Plan does not have to pre-approve the
consultation (D9310), core buildup (D2950), prefabricated post and core (D2954), crowns (D6750), pontics
(D6240), periodontal maintenance (D4910) and periodontal scaling and root planing (D4341).