Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fifteen (15) additional home PT visits and fourteen (14) additional home OT visits.
You asked the Plan to pre-approve fifteen (15) additional home PT visits and fourteen (14) additional home OT visits You say that the additional home PT and OT visits are medically necessary. The Plan denied your request. The Plan says the medical records submitted did not show that the enrollee meets the necessary criteria such as needing a therapist to continue the home exercise program. Any education and training should have already occurred with previous therapy visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 fifteen (15) additional home PT visits and fourteen (14) additional home OT visits. Our reviewer says that additional PT and OT is not medically necessary. Our physician reviewer found that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. There is no evidence of complex wound care or other ongoing skilled nursing need. The enrollee has had prior therapy and records do not show that skilled therapy services (PT or OT) are required for the enrollee's functional level to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. The request for home health services is not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fifteen (15) additional home PT visits and fourteen (14) additional home OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve fifteen (15) additional home PT visits and fourteen (14) additional home OT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
February 17, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you thought the
secondary payer would pick up the copayment. The Plan denied your request. The Plan says you were charged
the copayment correctly and you may send your Explanation of Benefits to the secondary payer.
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 $40
copayment for Physician services, specialist visit.
You have been asked to pay a $40 copayment for the specialist office visit. the specialist office visit falls
within the Physician services, specialist visit 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 specialist office visit provided on February 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care for right total shoulder arthroplasty (CPT code 23474), for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you need all the help you can get to recover after surgery. The Plan denied your request. The Plan says the procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation you will require a greater than two (2) midnight stay. The Plan states if you experience any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the documentation does not show that your medical history would warrant inpatient services that would likely cross two (2) midnights for this ambulatory procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care for right total shoulder arthroplasty (CPT code 23474), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 patient appears to be still requiring coronary care unit (CCU) and requires additional short-term acute care services which can be safely completed at the current facility until more stable. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, LTACH services will be considered not medically necessary at this time as there would be no significant clinical advantage to transfer at this time. Transfer may be considered when treatment has completed and the patient is more stable. 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp syringe.
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the provided documentation does not show a serum ferritin of at least 100 ng/mL (mcg/L) and a transferrin saturation (TSAT) of at least 20% measured within the previous 3 months.
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 Aranesp. Our reviewer says that the requested drug, Aranesp, is not medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that support that the Aranesp is medically reasonable and necessary for the enrollee. The reviewer found that the provided records do not show a serum ferritin of at least 100 ng/mL (mcg/L) and a transferrin saturation (TSAT) of at least 20% measured within the previous 3 months. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Specifically, the record does not indicate that a transferrin saturation of at least 20% measured within the previous 3 months. Therefore, we decided that the Plan does not have to pre-approve Aranesp syringe.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supplies rendered on March 12, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supplies rendered on March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on March 26, 2021.

You asked the Plan to waive the copayment for the lab services. You say that the cost of these lab services should be included with your annual physical. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for these lab services ($3.17) is less than your copayment obligation, you are responsible for the full allowed 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 $10 copayment for lab services. 

You have been asked to pay a $10 copayment for the lab services. Your Evidence of Coverage explicitly states that lab services are not part of your annual physical and that a separate lab copayment will apply. 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 lab services you received on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 26, 2021, to April 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained 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 physician services provided on April 26, 2021, to April 28, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided by an opted-out physician from May 27, 2020, to December 15, 2020.
You asked the Plan to pay for office services. You say that these services were paid in previous years, and you were told that if you received a letter from the provider stating that he had opted-out of Medicare you would be reimbursed in full. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider has opted-out of Medicare and is not payable.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 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. Therefore, we decided that the Plan does not have to pay for office services provided by an opted-out physician from May 27, 2020, to December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the periapical x-ray (D0220) provided on April 12, 2021.

You asked the Plan to pay the in network rate for the periapical x-ray. You say that you were under the impression that the dentist was in network. You also say that the dentist office also says they were in network. The Plan denied your request. The Plan says periapical x-ray is not listed as a covered service.

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 periapical x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the periapical x-ray (D0220) provided on April 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on September 30, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 99291 and 99292 are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. The definition of code 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). 

We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, there is no documentation of critical care services for an initial 30-74 minutes to support code 99291. Given that the primary procedure code is not covered, add-on code 99292 is also not supported. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services rendered on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic injection services coded 20526 provided on April 12, 2021.
You asked the Plan to pay for the therapeutic injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 20526 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the therapeutic injection services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic injection services coded 20526 provided on April 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care.
Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The record does not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on April 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that the services were medically necessary and deemed payable. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 office visit (99214) provided on April 28, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) and a power seat elevation system (E2300).
You asked the Plan to pre-approve an expandable controller and a power seat elevation system. You say that these items are medically necessary. The Plan denied your request. The Plan says the seat elevator is not covered, and you can operate the power options with their own switches.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when medically necessary for a function listed in the LCD. A power seat elevation system is non-covered because it is not primarily medical in nature. 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 an expandable controller and a power seat elevation system. Our reviewer says that the requested items are not medically necessary. Our physician reviewer found your strength and function in the upper extremities supports that you can control any power options through their own individual switches, meaning the expandable controller is not necessary. The power seat elevation system is not medical in nature and is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller and a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) and a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (77002) provided on July 23, 2020.
You asked the Plan to pay for the services. You say that The Plan denied your request. The Plan says that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provider a valid rationale for its denial of the requested services. The Plan did not submit medical records that were provided by the provider. Without a valid rationale and supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (77002) provided on July 23, 2020.
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.