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

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for IRF admission.
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 enrollee meets criteria for IRF admission. Our physician reviewer found based on review of the available records, the enrollee meets CMS coverage criteria for an IRF admission. He has medical complexity and does require a PM&R physician supervision 3 times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. He has documented rehabilitation nursing needs with wound care. He is at a functional level with dependency for activities of daily living, mobility and cognitive deficits and clearly needs an IRF level of care and requires an intensive, complex, multidisciplinary approach to daily therapy in an IRF. Documentation supports the need for therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. There is substantial evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. the enrollee needs physical and cognitive rehabilitation in an IRF. IRF admission is medically 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration procedure (20939).
You asked the Plan to pre-approve bone marrow aspiration procedure. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.
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 bone marrow aspiration procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 78-year-old female who has been approved for spinal fusion surgery. However, detailed documentation is not evident regarding a specific indication provided to support the request for bone marrow aspirate for the approved surgery.
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for bone marrow aspiration (20939) is not 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 bone marrow aspiration procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration procedure (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections (64491) provided on March 4, 2021.

You asked the Plan to pay for facet joint injections. You say that this is supported in the records. The Plan denied your request. The Plan says this exceeds MUE.

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 64491 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint injections (64491) provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs you received from
March 3, 2021, to March 31, 2021.
You asked the Plan to waive the coinsurance for the Medicare Part B drugs. You say that in previous years, the
cost for this treatment was less. You also stated that the medication applied during these services is too
expensive and you have had to request your doctor stop using this medication as a result. The Plan denied your
request. The Plan says the way your doctor billed for these services in the past may have been different. The
Plan says that you were charged this coinsurance correctly.
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 20%
coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Medicare Part B drugs. The Medicare-allowed rate for the
drugs you received on each date is $752.96. Since you are responsible for 20% coinsurance for Medicare Part
B drugs, that means for each date of service, your coinsurance obligation is $150.59. 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 Medicare Part B drugs you received from March 3, 2021, to March 31, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on
February 4, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee was not treated by a Medicare eligible provider.
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says
that outpatient mental health care requires prior authorization and is the responsibility of the provider.
The records do not show that the Plan pre-approved this service. Therefore, we decided that the Plan does not
have to pay for outpatient mental health care provided to the enrollee on February 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued SNF services. 
 
You asked the Plan to provide coverage for continued SNF services. You say that you needed emergency 
surgery that required an additional stay in the SNF.  The Plan denied your request. The Plan says you have 
exhausted the 100-day SNF benefit on June 27, 2021. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from March 4, 2021, through 
May 4, 2021 and May 20, 2021, through June 27, 2021. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81521) rendered by the out-of-network (OON) provider on March 10, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (81521) rendered by the out-of-network (OON) provider on March 10, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the home health aide services provided March 12, 2019, to April 9, 2019.
You asked the Plan to pay for the home health aide services. You say that all services were provided to this enrollee under signed physician orders and were deemed to be medically necessary. The Plan denied your request. The Plan says that per the pricer, which is based on the supply lines, were not billed per CMS guidelines for payment.
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 failed to substantiate the reason for the denial. Please note, the HIPPS code submitted on the claim was valid on the billed date of service. The plan has failed to provide a clear explanation on why the services were denied. Therefore, we decided that the Plan has to pay for the home health aide services provided March 12, 2019, to April 9, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug services rendered from February 26, 2021 to February 27, 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 the services were not billed correctly.

The Plan must follow Medicare rules. The rules say that the AY modifier serves as an attestation that the item or service is medically necessary for the dialysis patient but is not being used for the treatment of ESRD. 

We looked at the file and Medicare rules. The file shows that billed procedure code J0604 (oral cinacalcet) was not billed with the required AY modifier. 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 services rendered from February 26, 2021 to February 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen and oxygen supplies and routine disposable supplies provided on December 17, 2020.
You asked the Plan to pay for the oxygen and oxygen supplies and routine disposable supplies. The Plan denied your request. The Plan says codes A0422 and A0398 remain denied as not covered under Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, is included in the fee schedule payment. We looked at the file and Medicare rules. Medicare says that payment for items and services, such as oxygen, is included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for oxygen and oxygen supplies and routine disposable supplies provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider on May 25, 2021.

You asked the Plan to waive the copayment for an office visit. You say that you should only have one 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 $15 copayment for physician/practitioner services/PCP. 

You have been asked to pay a $15 copayment for an office visit. An office visit falls within the physician/practitioner services/PCP 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 office visit provided by a participating provider on May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement below-knee socket (L5700) to be provided by an out-of-network provider.
You asked the Plan to pre-approve a replacement below-knee socket. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve a replacement below-knee socket (L5700) to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on April 9, 2021, to April 22, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment you are being charged is 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). Your contract with the Plan clearly says that you must pay a $275 copayment per day, for days 1-6 for inpatient hospital care. Your contract with the Plan also clearly says that enrollees pay $0 for days 7 to 90 for inpatient hospital care. 

You have been asked to pay a $275 copayment per day for inpatient hospital care ($275 x 6 days = $1,650). The EOC confirms that $275 is the required copayment for this service. 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 inpatient hospital care provided on April 9, 2021, to April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tooth extractions (D7210) to be provided by an oral surgeon.
You asked the Plan to pre-approve tooth extractions to be provided by an oral surgeon.. You say that you need this service because you are in constant pain. The Plan denied your request. The Plan says this is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit when they are performed by an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve tooth extractions (D7210) to be provided by an oral surgeon.
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 the SNF services. You say that the enrollee is participating in physical and occupational therapy. You say that the records provided support the need for care in a SNF. The Plan denied your request. The Plan says SNF care is not reasonable and required to treat the enrollee's condition. The Plan says that the enrollee's needs can be met at home or an assisted living facility .
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was started on hemodialysis. The enrollee received physical therapy and occupational therapy. By the dates in question, the enrollee had declined and had poor participation. However, the enrollee could move in bed with supervision. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment (A0998) provided on October 17, 2020.
You asked the Plan to pay for the ambulance response and treatment. You say that you would like reconsideration because there were no other options for the member's transport. The Plan denied your request. The Plan says if no transport of a Medicare beneficiary occurs; there is no Medicare covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 17, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment (A0998) provided on October 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is not covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Interspinous process devices remain experimental in cases of spinal surgery. More research is needed to show safety and efficacy of interspinous process devices. 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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit you had with a pain management specialist on March 11, 2021, the arthrocentesis procedure you had at an outpatient hospital facility on April 5, 2021, and the epidural injection procedure you had at an outpatient hospital facility on April 5, 2021, and May 7, 2021.
You asked the Plan to waive the copayments for the specialist visit and outpatient hospital procedures. You say that you were not aware that these services would be billed as outpatient surgery. You feel that you should just have a $20 office visit copayment for these dates. The Plan denied your request. The Plan says you were charged these copayments correctly.
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 $50
copayment per visit for outpatient surgery and services at hospital outpatient facilities and a $20 copayment for specialist visits. You have been asked to pay a $50 copayment per visit for the outpatient hospital procedures and a $20 copayment for the specialist visit. 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 copayments for the office visit you had with a pain management specialist on March 11, 2021, the arthrocentesis procedure you had at an outpatient hospital facility on April 5, 2021, and the epidural injection procedure you had at an outpatient hospital facility on April 5, 2021, and May 7, 2021.