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

We decided that the Plan has to waive the coinsurance for home infusion therapy services provided from February 14, 2020, to April 27, 2020.
You asked the Plan to waive the coinsurance for home infusion therapy services. You say that you would like reconsideration of these claims and the amounts due. The Plan denied your request. The Plan says that the coinsurance amounts the enrollee is being charged are correct.
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 Plan contract does not say in clear and accurate terms how much enrollees should expect to pay for home infusion therapy code S9502. Procedure code S9502 represents a combination of professional services, supplies, and equipment billed as a per day (per diem) charge. This code is not valid for Medicare purposes. When the separate items and services described by this code are combined into a single code, it cannot be determined how much of the charged amount represents each individual item or service. We looked at the contract between the enrollee and the Plan. We did not see where the contract says enrollees must pay 20% coinsurance for a code which combines charges for medical supplies and professional services. The Plan contract does not clearly say how much enrollees must pay for a code which combines charges for medical supplies and professional services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for home infusion therapy services provided from February 14, 2020, to April 27, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attendant services.
You asked the Plan to pre-approve attendant services. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that custodial care is excluded from coverage. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of attendant services have not been met. Therefore, we decided that the Plan does not have to pre-approve attendant services.
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 you need physical and speech therapy to be able
to return home. The Plan denied your request. The Plan says that the services you require are custodial.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.

You asked the Plan to pre-approve Retacrit. You say that the medication is 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. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage.

Please note that this drug has been approved for coverage under the enrollee's Part D coverage. If you would
prefer this drug to be covered under the enrollee's Part B benefit, please contact the Plan directly to indicate
that you (the provider) intend to buy and bill this drug and feel Part B coverage should apply. Therefore, we
decided that the Plan does not have to pre-approve Retacrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a transfer device (E0705) and a wheelchair battery (E2361) provided on October 5, 2020.
You asked the Plan to pay for a transfer device and a wheelchair battery. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a transfer device (E0705) and a wheelchair battery (E2361) provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services provided on October 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for dermatology services. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for dermatology services provided on October 30, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation provided by an out-of-network
provider on June 8, 2021.

You asked the Plan to pay for the telephone evaluation. You say that you were not aware the patient had an
HMO plan so a referral was not obtained. You say that the services were rendered due to their chronic medical
conditions and the claim should be reconsidered. The Plan denied your request. The Plan says this provider is
not a network provider with the Plan and the services were not referred by a 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 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 telephone evaluation provided by an out-ofnetwork
provider on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 1, 2020.
You asked the Plan to pay for evaluation and management of a new patient (99204). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee was seen on December 10, 2019 by this provider therefore the enrollee is not a new patient.
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 99204 is office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. We find that CPT code 99204 is not supported in the medical record. Specifically, the claims record shows that the enrollee has been seen by this provider within the last 3 years. Based on this information, we decided that Medicare rules for coverage of evaluation and management of a new patient (99204) have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on December 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 9, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there are no medical records for this provider on the billed date of service.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the record does not include medical records for the billed date of service. Without these records, the billed services cannot be verified and we are unable to determine if Medicare criteria have been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need to do therapy and are not able to be taken care of at home. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would benefit from acute physical and occupational rehab. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMs device.
You asked the Plan to pre-approve a CardioMEMs device. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a CardioMEMs device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found given the severe symptoms of recurrent congestive heart failure coupled with the complex pulmonary disease which appears very sensitive to volume loading conditions, the complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this enrollee, use of the CardioMEMs device is reasonable in this specific clinical situation and has both clinical data and expert opinion to back up its use. It would therefore meet the applicable CMS Section 1862(a) medical necessity and reasonableness criteria. 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 CardioMEMs device have been met. Therefore, we decided that the Plan has to pre-approve a CardioMEMs device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is not a covered service.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hydrogen breath test (CPT code 91065), for the enrollee.
You asked the Plan to pre-approve the services. You say that the Plan should reconsider coverage for hydrogen breath test to evaluate for small bacterial overgrowth based on the enrollee's persistent and uncomfortable symptom abdominal bloating. The Plan denied your request. The Plan says lactulose breath hydrogen testing for diagnosing small bowel bacterial overgrowth and measuring small bowel transit time is specifically listed as not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The rules say that the Following Breath Tests are Excluded from Coverage: Lactulose breath hydrogen for diagnosing small bowel bacterial overgrowth and measuring small bowel transit time. Therefore, we decided that the Plan does not have to pre-approve a hydrogen breath test (CPT code 91065), for the enrollee.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to correctly assess the coinsurance for the outpatient surgery. We decided that the Plan does not have to waive the coinsurance for outpatient surgery.

You asked the Plan to waive the coinsurance for the outpatient surgery. You say that there is no transparency from the Plan regarding your charges. The Plan says that that you are responsible for the cost-sharing.

We decided that the Plan has to correctly assess the coinsurance for the outpatient surgery.

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% coinsurance for each Medicare-covered outpatient hospital facility visit. 

The file shows that the Plan did not correctly assess the coinsurance for your outpatient surgery. The allowable charge according to the explanation of benefits was $7,194.27. 10% of these charges is $719.43.

The Plan charged a coinsurance of $799.27. Therefore, we decided that the Plan has to correctly assess the coinsurance for the outpatient surgery.

We also decided that the Plan does not have to waive the coinsurance for outpatient surgery.

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 an 70 coinsurance for the outpatient surgery. Therefore, we decided that the Plan does not have to waive the coinsurance for outpatient surgery.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dermatology office visit.
You asked the Plan to pre-approve dermatology services. You say that the hemangioma is irritated and getting bigger. The Plan denied your request. The Plan says a dermatologist is not medically necessary for your condition.
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 dermatology services. Our physician reviewer found that you have had he hemangioma in the middle of his back about 20 years. You have been informed that the hemangioma needs to be removed. There is no specific clinical rationale for evaluation by dermatology. The records do not show that dermatology services are medically reasonable or 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 dermatology services have not been met. Therefore, we decided that the Plan does not have to pre-approve a dermatology office visit.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (27125) provided on September 15, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 27125 is "Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)". 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 use of CPT code 27125 is not supported by the records provided. Our coding reviewer found that per the CPT manual, CPT code 27125 is reported for degenerative changes, not fracture conditions. CPT 27236 (open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement) would be used to report a hemiarthroplasty for a hip fracture. Therefore, CPT 27125 is an inappropriate code to report for procedure performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (27125) provided on September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bed side rails (E0310), raised toilet seat (E0244) and transfer bench (E0248) provided July 25, 2020, to September 22, 2020.
You asked the Plan to pay for bed side rails, raised toilet seat, and transfer bench. You say that these items were not just for convenience purposes. The Plan denied your request. The Plan says these items are not covered.
The Plan must follow Medicare rules. Medicare rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that a raised toilet seat is not covered and that bed side rails will only be covered as an accessory to a covered hospital bed.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bed side rails, raised toilet seat, and transfer bench have not been met. Therefore, we decided that the Plan does not have to pay for bed side rails (E0310), raised toilet seat (E0244) and transfer bench (E0248) provided July 25, 2020, to September 22, 2020.