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

We decided that the Plan does not have to pay forthe skilled nursing services provided from June 7, 2019 to July 6, 2019.You asked the Planto pay forthe skilled nursing services. You say that the services that the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require any additional skilled servicesthat could not have been provided in an alternate setting other than a SNF.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked ourphysician 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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care.  Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from June 7, 2019 to July 6, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for acute inpatient hospital care provided May 23, 2019 to May 25, 2019.
You asked the Plan to pay for acute inpatient hospital care. You are requesting review of the documentation
provided and approval based on medical necessity. The Plan denied your request. The Plan says this met an
observation level of care but it did not qualify as an inpatient admission.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment were met in this case. Our physician
reviewer found that the enrollee was transferred to the emergency department (ED) from another facility on
May 23, 2019 for the evaluation of chest pain with radiation to the left arm, dizziness and headache. On
evaluation the vital signs were stable and the physical exam was unremarkable. The enrollee was evaluated by
Cardiology and admitted to telemetry. She underwent an echocardiogram, carotid studies, MRI of the brain,
and an abdominal/pelvic CT. Her blood glucose was controlled with sliding scale insulin and her medical
regimen was adjusted. A cardiac catheter was planned but not performed. Her condition stabilized and
improved and she was discharged home on May 25, 2019 when considered medically stable. The review has
determined that the record showed that at the time of inpatient admission the admitting physician reasonably
expected that the patient's necessary hospital care (including earlier ED and/or observation 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 been met. Therefore, we decided that the Plan
has to pay for acute inpatient hospital care provided May 23, 2019 to May 25, 2019.
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 pay for a laparoscopy (45400) provided on August 9, 2019.You asked the Plan to pay for the laparoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 45400 is included in another service that was provided at the same time by the same provider.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, we have confirmed that code the laparoscopy has a bundled relationship with code 45402 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a laparoscopy (45400) provided on August 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The enrollee has acute care medical needs that still need to be addressed prior to being able to fully participate in a rehabilitation program. The documentation does not reveal that the enrollee is able to tolerate the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on October 12, 2019.
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges because
you were told that you would not owe a copayment. The Plan denied your request. The Plan says the claims
were processed correctly and you are being charged the correct 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 $15
copayment for X-rays.
You have been asked to pay a $15 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests
and therapeutic services and supplies 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
an X-ray provided on October 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET scan of the brain for the enrollee.You asked the Plan to pre-approve the scan. You say that this is medically necessary.The Plan denied your request. The Plan says the records do not show that the supported indications for the scan are present.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found CMS criteria specify that PET is necessary if there is a question of Alzheimer's dementia versus FTD and the latter diagnosis is not mentioned in the neurologist's discussion.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 scan have not been met.Therefore, we decided that the Plan does not have to pre-approve PET scan of the brain for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on July 3, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to the enrollee on July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit provided on October 15, 2019.You asked the Plan to waive the copayment foran office visit. You say that this was a wellness visit and you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $15 copayment for primary care provider visits received from a standard primary care physician. The medical records show that you received services beyond an annual wellness visit on October 15, 2019. Therefore, you are responsible to pay the $15 copayment. You have been asked to pay a $15 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 foran office visit provided on October 15, 2019. h
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).You asked the Plan to pre-approveDurolane. You say that the requested medication is necessary.The Plandenied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement steptherapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Durolane. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee has received Monovisc, but not Orthovisc. The documentation does not support that Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met.Therefore, we decided that the Plan does not have to pre-approveDurolane (J7318).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on October 2, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says these services require prior authorization.
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 has network providers
available who can provide 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 services provided to the enrollee on October 2,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0652) and segmental
pneumatic sleeve (E0667).
You asked the Plan to pay for a pneumatic compression device and sleeve. You say that you disagree with the
denial and request review of the supporting documentation and request reconsideration for coverage. The Plan
denied your request. The Plan says there was no failed four week trail with a basic pneumatic compression
device, E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
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, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device
(E0652) and segmental pneumatic sleeve (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that you need the new shower chair because you are in a wheelchair and are unable to stand. You say that you are appealing because it is an urgent matter.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a shower chair
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto 20mg tablets.You asked the Plan to pre-approveXarelto. You say that Xarelto is medically necessary.The Plan denied your request. The Plan says Xarelto is not eligible for coverage under the Part B medical benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Xarelto 20mg tablets.Benefits for Xareltomay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forurine drug testing services provided to the enrollee on August 20, 2019.You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services are available in-network.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 has network providers available who can provide 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 Plandoes not haveto pay forurine drug testing services provided to the enrollee on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray, each additional intraoral periapical x-ray, and amalgam provided on October 29, 2019.You asked the Plan to pay forthe first intraoral periapical x-ray, each additional intraoral periapical x-ray, and amalgam. You say that the provider told you the x-rays would be bitewings and you would only pay $54 for your filling.The Plan denied your request. The Plan says the x-rays are not a covered benefit under your dental plan. The Plan also says that a composite resin restoration on a posterior tooth is not a benefit of the dental Plan. The Plan says that the allowance was established under the optional service provision in the dental Plan.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 dentalbenefit in excess of Medicare coverage, periapical x-rays are not among those covered under this benefit. The contract also clearly states that you must pay 50% coinsurance for fillings and crown repair. The Plan is only obligated to pay 50% cost share for fillings and crown repair. The record shows that the Plan correctly charged you for the amalgam and you are responsible for the remaining amount.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray, each additional intraoral periapical x-ray, and amalgam provided on October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to the enrollee on April 2, 2019.You asked the Plan to pay forthe lab services. The Plandenied your request. The Plan says he billed codes 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 code.The file shows thatthe enrollee received presumptive and definitive drug testing. The records do not indicate that the specimen was taken at an independent laboratory. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay forthe lab services provided to the enrollee on April 2, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for subsequent Inpatient Hospital Care (99233) provided on October 7, 2019 to October 8, 2019 by Vivek Verma, MD.
You asked the Plan to pay for the inpatient hospital care. You say that the enrollee was admitted through the Emergency Room and the care provided was medically necessary. The Plan denied your request. The Plan says that these out-of-network services were not preauthorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider at issue in this case is not a network provider with the Plan. 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 inpatient physician services at issue. Our reviewer says the services at issue were medically necessary and urgent in nature. Our physician reviewer found the records show the enrollee suffered from acute respiratory failure with hypoxia, myocardial infarction and pneumonia. The enrollee was admitted from the Emergency Room. It would not be practical to transfer the enrollee to an in-network facility in their condition. 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 inpatient physician services have been met. Therefore, we decided that the Plan has to pay for subsequent Inpatient Hospital Care (99233) provided on October 7, 2019 to October 8, 2019 by Vivek Verma, MD.
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 the medical services provided on October 1, 2019 to the enrollee by an out of network (OON) provider.
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 were rendered by a non-network provider without prior authorization.
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 has network providers available who can provide 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 medical services provided on October 1, 2019 to the enrollee by an out of network (OON) provider.