Persius/hicric huggingface dataset:
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 must complete your full course of acute hospital treatment.
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 COVID 19 pneumonia. Your medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the routine vision services rendered on October 27, 2020.
You asked the Plan to reimburse you for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was processed correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to a $175 vision allowance every year for routine eyewear. We looked at the file and the Plan's rules. The file shows that the Plan applied $50 for your routine vision services on October 6, 2020 and $125 on October 27, 2020. At this time, the full $175 benefit had been applied. Further reimbursement is not covered by Medicare or your supplemental benefit. Therefore, we decided that the Plan does not have to reimburse you for the routine vision services rendered on October 27, 2020.
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 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. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99285) provided on September 13, 2020.
You asked the Plan to pay for an emergency room visit. You say that this was billed with an acceptable primary diagnosis. The Plan denied your request. The Plan says the billed primary diagnosis is not valid.
The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. We looked at the file and Medicare rules. The billed primary diagnosis, G92, has a "code first" note, indicating it is a manifestation code that should not be coded before the etiology code. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99285) provided on September 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Atezolizumab.
You asked the Plan to pre-approve Atezolizumab. You say that the requested Atezolizumab is medically necessary. The Plan denied your request. The Plan says the requested Atezolizumab is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Atezolizumab. Our reviewer says that the requested Atezolizumab is not medically necessary. Our physician reviewer found the enrollee is diagnosed with ER-, PR weakly _, her 2 neu negative breast cancer, metastatic. This enrollee is PR+, she is not triple negative. As such, the requested drugs are not indicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Atezolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Atezolizumab.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hospital outpatient clinic visit (G0463) provided on March 3, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the Hospital outpatient clinic visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were provided without a referral and do not meet OON criteria.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the Hospital outpatient clinic visit (G0463) provided on March 3, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the nerves innervating the sacroiliac joint.
You asked the Plan to pre-approve radiofrequency ablation of the nerves innervating the sacroiliac joint. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 radiofrequency ablation of the nerves innervating the sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee a diagnosis of Sacrococcygeal disorders, not elsewhere classified. The enrollee has low back pain and lumbar radiculopathy. A laminectomy has been performed. The enrollee has undergone 3 sacral iliac injections and sacral lateral branch blocks. The enrollee reported 80% relief. The documentation does not support long-term clinical benefit from radiofrequency ablation of the sacroiliac joint. Therefore, the enrollee does not meet criteria for the requested 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 radiofrequency ablation of the nerves innervating the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the nerves innervating the sacroiliac joint.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided on November 2, 2020.
You asked the Plan to waive the copayment for the EKG. You say that the test was done in the outpatient diagnostic center. You say that an EKG was always paid as done in the diagnostic center. The Plan denied your request. The Plan says the copayment applied 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 for diagnostic procedures and tests at an in-network outpatient hospital. You have been asked to pay $49.69, which is less than the standard $50 copayment for the EKG. The EKG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the EKG was billed by the hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the EKG provided on November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental core buildups (D2950), pontic (D6245), and retainer crowns (D6740) provided on October 27, 2020.
You asked the Plan to pay for dental services. You say that according to your policy these services are covered, and these charges are becoming a financial strain for you. The Plan denied your request. The Plan says the denial of payment for these services is correct, because you previously received a covered core buildup (D2950) on September 22, 2020 and the pontic and crowns are not covered by the Plan's dental benefits.
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. The Plan offers a dental benefit in excess of Medicare coverage. You previously received a covered core buildup on September 22, 2020; therefore, this benefit was exhausted for this date of service. The pontic and retainer crowns are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental core buildups (D2950), pontic (D6245), and retainer crowns (D6740) provided on October 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection and copayment for a PET scan provided by a participating provider on September 29, 2020.
You asked the Plan to waive the coinsurance for an injection and copayment for a PET scan. You say that you cannot afford this bill. The Plan denied your request. The Plan says the correct copayment and 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 and a $150 copayment for Medicare Part B prescription drugs and outpatient diagnostic tests/PET scan. You have been asked to pay a 20% coinsurance of the allowed amount for an injection and a $150 copayment for a PET scan. The total allowed amount is $213.05. The amount you are being asked to pay for an injection is $42.61 ($213.05 x 20% = $42.61). The total amount you are being asked to pay is $192.61 ($150 + $42.61 = $192.61). An injection falls within the Medicare Part B prescription drugs benefit category and a PET scan falls within the outpatient diagnostic tests/PET scan 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 and copayment for an injection and a PET scan provided by a participating provider on September 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 5, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you took two ambulance rides and were advised you only had to pay $300. You say that you are only paying one $300 copayment. The Plan denied your request. The Plan says the copayment applied 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 $300 copayment for each Medicare-covered trip (one-way). You have been asked to pay a $300 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The Evidence of Coverage clearly states the copayment applies to each one-way ambulance trip. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert medical alert system.
You asked the Plan to pre-approve a Life Alert medical alert system. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that telephone alert systems are emergency communications systems and do not serve a diagnostic or therapeutic purpose. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Life Alert medical alert system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Life Alert medical alert system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve rendered on September 7, 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 there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve rendered on September 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery services for tissue transfer surgery provided on October 8, 2020.
You asked the Plan to pay for surgical assistance service. You say that an assistant surgeon is payable for this procedure. The Plan denied your request. The Plan says the denial of payment for this service is correct, because surgical assistant service is not covered by Medicare for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 14040. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistance service have not been met. Therefore, we decided that the Plan does not have to pay for assistant at surgery services for tissue transfer surgery provided on October 8, 2020.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says 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 does not meet criteria for IRF admission. Our physician reviewer found based on the medical records provided 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. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 4, 2020.
You asked the Plan to pay for the knee orthosis (L1833LT) and suspension sleeve (L2397LT). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee's claim history shows that there are no claims from the ordering physician.
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 knee orthosis (L1833LT) and suspension sleeve (L2397LT). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthosis (L1833LT) and suspension sleeve (L2397LT) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotics (L3960, L1951) provided October 6, 2020.
You asked the Plan to pay for the orthotics. You say that the items were medically necessary. The Plan denied
your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code L3960, & L1951 is not supported in the medical record. Specifically, the diagnosis code
submitted shows a laterality of unspecified, while the CPT codes billed used modifiers that showed LT and RT
(left and right) laterality. Based on this information, we decided that Medicare rules for coverage of the
orthotics have not been met. Therefore, we decided that the Plan does not have to pay for orthotics (L3960,
L1951) provided October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on January 16, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99203 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99203 is outpatient visit for evaluation and management of new patient, including medically appropriate examination and low level of medical decision making, total time 30-44 minutes. We find that CPT code 99203 is not supported in the medical record. Specifically, this code is for a new patient office visit and the file shows that the enrollee was seen by the same provider group within the past three years; therefore, a new patient office visit does not apply. 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 office visit rendered on January 16, 2020.