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

We decided that the Plan does not have to pay for the home visit for the evaluation and management services provided to the enrollee from August 6, 2019.
You asked the Plan to pay for the home visit for the evaluation and management 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 payable.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for the home visit for the evaluation and management services have not been met. Specifically, this code may only be billed when services are provided in the enrollee's private residence (place of service 12). This service was not billed with the appropriate place of service. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management services provided to the enrollee from August 6, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve right bronchial valve placement (Zephyr) and bronchoscopy with balloon occlusion for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the procedure is considered experimental and investigational.

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 requested services are considered medically reasonable and necessary in this case. This procedure is no longer considered experimental, and has been shown in randomized, sham-controlled trials to provide significant clinical benefits for selected patients with severe chronic obstructive pulmonary disease and emphysema with air trapping. The benefits have been shown to be durable. This patient meets the criteria established in the clinical trials. Our physician reviewer found that the enrollee's condition meets criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-approve right bronchial valve placement (Zephyr) and bronchoscopy with balloon occlusion 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the routine transportation 30-mile limit for the enrollee.

You asked the Plan to pre-approve this exception. You say that this transport is medically necessary. The Plan denied your request. The Plan says exceptions are not made to supplemental transportation benefits.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage.

For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 30 miles one way. Therefore, we decided that the Plan does not have to pre-approve an exception to the routine transportation 30-mile limit for the enrollee.
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 your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter you do not require the necessary services on an inpatient basis, in a skilled nursing facility 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than a 2 midnight stay.
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 pay for inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The enrollee is scheduled for an elective right total shoulder arthroplasty. The patient has a history of sarcoidosis and chronic kidney disease, however, there is no indication from the provided notes that this low-risk surgery would require hospital services that would likely cross two midnights as there are no expected complications or prolonged recovery. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Mycophenolat.
You asked the Plan to pre-approve a tier exception for Mycophenolat. You say that the exception is needed. The Plan denied your request. The Plan says the drug does not qualify for tier exceptions.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Mycophenolat have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Mycophenolat.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to an inpatient psychiatric facility for the enrollee.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient psychiatric hospital services. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found as of 7/20/21, the enrollee presented to the emergency department due to confusion and medication refusal. No clinical information was provided to explain or justify the delay in timely notification of admission to inpatient behavioral health. Notification of admission first occurred on 07/12/2021. The provider was not able to deliver any time stamped documentation or clinical evidence to justify the delay in notification of admission. Thus, the admission days should be approved.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve admission to an inpatient psychiatric facility 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: 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 these services are medically necessary. The Plan denied your request. The Plan says that you do not require close supervision by a rehab doctor face-to-face three times a week, do not require 15 hours of therapy per week and do not require a coordinated multi-team approach to rehab.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for abdominal pain and were treated for a liver fistula. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on January 12, 2021.

You asked the Plan to waive the coinsurance for an injection. You say that you are on social security and cannot afford this. The Plan denied your request. The Plan says the correct coinsurance 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% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $13,708.32. The total amount you are being asked to pay is $2,741.66 ($13,708.32 x 20% = $2,741.66). The correct coinsurance has been applied to the injection that was provided.

An injection falls within the Medicare Part B prescription drugs 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 provided by a participating provider on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided June 4, 2020.
You asked the Plan to pay for the critical care services coded as 99291. You say that these services were performed as billed. The Plan denied your request. The Plan says this code as billed is not supported in the medical records submitted.
The Plan follows Medicare rules. Medicare rules say that the physician's progress note(s) shall document the total time that critical care services were provided. 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 critical care services coded as 99291. Our reviewer says that the requested service is not supported by the submitted medical records. Our physician reviewer found in this case the enrollee underwent, left heart catherization and stenting of the right coronary artery. The provided documentation does not include the amount of critical care time provided. The elements of the billing rule are not satisfied.
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 critical care services coded as 99291 have not been met. Therefore, we
decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill
or critically injured patient; first 30-74 minutes (99291) provided June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on March 8, 2021.
You asked the Plan to waive the copayment for specialist services. You say that this should be a $0 copayment. 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 $35 copayment for physician/practitioner services/specialist. You have been asked to pay a $35 copayment for specialist services. The hearing exam that was provided had a $0 copayment. The copayment that was applied was for the specialist services that were provided. Specialist services falls within the physician/practitioner services/specialist 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 specialist services provided by a participating provider on March 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance services (A0429) provided on December 30, 2020.

You asked the Plan to waive the copayment for emergency ambulance services. You say that the services should be covered. The Plan denied your request. The Plan says 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 $275 copayment for ambulance services. 

You have been asked to pay a $275 copayment for emergency ambulance services. The service at issue falls within the ambulance 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 emergency ambulance services (A0429) provided on December 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for abscess drainage (10061) provided on August 1, 2020.

You asked the Plan to pay for abscess drainage. You say that this was billed correctly. The Plan denied your request. The Plan says there is a more appropriate code for this 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 10061 is incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple. 

We find that CPT code 10061 is not supported in the medical record. Specifically, the records show that only one abscess was treated, and it is documented that there were no complications. Based on this information, we decided that Medicare rules for coverage of abscess drainage have not been met. Therefore, we decided that the Plan does not have to pay for abscess drainage (10061) provided on August 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight manual wheelchair and accessories.

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 the objective medical progress notes do not support that you have a mobility limitation that significantly impairs the ability to complete MRADLs, and is not able to resolved by a cane, walker, etc. There is no objective home evaluation. There is no evidence the manual wheelchair will significantly improve your ability to participate in MRADLs. There is no detailed gait or neuromuscular examination of the upper and lower extremities. There is no evidence that you cannot be propelled in a standard wheelchair in the home. 

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 lightweight manual wheelchair and accessories.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided from November 24, 2020, through January 16, 2021.

You asked the Plan to pay for the home health care 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. 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 home health care services provided from November 24, 2020, through January 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile x-ray services rendered on October 21, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component
(TC) indicator of 3 represents TC only codes.
We looked at the file and Medicare rules. Billed procedure codes R0070 (transportation of portable x-ray
equipment) and Q0092 (set-up portable x-ray equipment) have a PC/TC indicator of 3 and no separate PC
payment. 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 mobile x-ray services rendered on
October 21, 2020.