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

We decided that the Plan does not have to waive the copayment for an MRI and does not have to waive the
coinsurance for a Medicare Part B drug provided on November 5, 2019.
You asked the Plan to waive the copayment for an MRI and to waive the coinsurance for a Medicare Part B
drug. You say that you disagree with the additional 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 $250
copayment for advanced imaging services. Your contract with the Plan also clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You received an MRI on November 5, 2019. Therefore, you are responsible to pay the $250 copayment.
You received a Medicare Part B drug on November 5, 2019. The allowed amount is $33.65 and 20% of that is
$6.84.
The total amount you owe is: $256.84.
You have been asked to pay the total amount of $256.84 for an MRI and a Medicare Part B drug. An MRI falls
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B
drug falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an MRI and does not have to waive the coinsurance for a Medicare Part B drug provided on
November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says here is no objective evidence of persistence of chronic and severe lymphedema.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the medical records provided, there is no detailed documentation that conservative treatment
over four weeks has failed and there is no detailed documentation of four weeks of trial of a non-segmental
pneumatic compression device.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve a pneumatic compression device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora reaching device (A9281)You asked the Plan to pay forthe reaching device. You say that you'd like the Plan to reconsider.The Plan denied your request. The Plan says it does not meet the definition of DME because it does not serve a medical purpose.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pay fora reaching device (A9281)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services coded
99239 provided on July 12, 2020.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like the
plan reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported
by the documentation.
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 99239 is hospital discharge day management; more than
30 minutes.
We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge
summary does not support hospital discharge day management of more than 30 minutes was performed. A
documented duration of time of 31 minutes or more is required to support this code. Based on this information,
we decided that Medicare rules for coverage of the hospital discharge day management services have not been
met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management
services coded 99239 provided on July 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee requires IRF care and meets the criteria for coverage.The Plan denied your request. The Plan says the records do not show that the enrollee needs to be seen by a rehab doctor 3 times a week or that an intensive team is needed for care. The Plan says that the enrollee can safely receive the services needed in another setting.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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a heart attack and congestive heart failure. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation provided on September 29, 2020, through September 30, 2020.
You asked the Plan to waive the copayment for emergency room services. You say that you should not have to pay the copayment. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient hospital observation. You have been asked to pay a $250 copayment for outpatient hospital observation services. The services at issue fall within the outpatient hospital observation 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 observation provided on September 29, 2020, through September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural injection (62321).
You asked the Plan to pre-approve an epidural injection. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that if a prior epidural injection procedure provided limited or no relief (i.e., NPRS less than 3, less than 50% symptom improvement, insignificant or indiscernible relief), a second epidural injection utilizing the same method, technique or medication to the same level will be considered not medically reasonable and necessary. A second injection involving a change in technique or medication will be considered following re-evaluation of the patient. We looked at the file and Medicare rules. The submitted medical records do not document that the enrollee received sufficient relief from the previous injection or tat a different method will be used for the requested injection. Based on this information, we decided that Medicare rules for coverage of an epidural injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural injection (62321).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe androgen receptor (AR) genetic testing rendered on July 13, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. Medicare rules say that procedure code 81204 is non-covered.We looked at the file and Medicare rules. The provider submitted a claim for procedure code 81204. This code is not covered by Medicare.Therefore, we decided that the Plan does not have to pay forthe androgen receptor (AR) genetic testing rendered on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies for drug infusion catheter coded A4221, A4222,
and J9190 provided on November 17, 2019.
You asked the Plan to pay for the supplies for drug infusion catheter. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the documentation did not include a valid
physician order.
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 physician order for the supplies provided in this case. The submitted
documentation contained a physician's order with the date after the billed date of service. 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 the supplies for drug infusion catheter coded A4221, A4222, and
J9190 provided on November 17, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray provided on August 17, 2020.
You asked the Plan to pay for the complete series x-ray. You say that you were informed they accepted your
insurance and there wouldn't be an extra charge. You say that you don't have the money to pay. The Plan
denied your request. The Plan says the frequency limitation has been exceeded.
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 Plan also has a maximum benefit
of one complete series or panoramic x-ray every three years. The Plan paid for a panoramic x-ray provided on
December 3, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for
the complete series x-ray provided on August 17, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs more therapy that cannot be done 
at home. The Plan denied your request. The Plan says this would be custodial care. 
 
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 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 from a nursing perspective, the beneficiary 
received oral medications and had stable vital signs. Regarding rehabilitation services, the beneficiary received 
physical, speech, and occupational therapy in the acute hospital and SNF. The beneficiary was at a dependent 
to moderate/maximal assist level with functional mobility.  The beneficiary required varying assist with 
activities of daily living. The beneficiary does not require skilled nursing or therapy services on a daily basis 
and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing 
facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve infliximab (J1745).
You asked the Plan to pre-approve infliximab. You say that this is medically necessary. The Plan denied your request. The Plan says that this medication is not indicated for the enrollee.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 infliximab. Our reviewer says that the requested infliximab is indicated for the enrollee in this case. Our physician reviewer found based on the records provided, the enrollee is finally having some improvement in her joint pain and stiffness. Morning stiffness improved to 30 minutes, but now after 3 weeks, she is having an hour of morning stiffness. Pain and swelling in her hands and feet also are feeling better. The enrollee has morning stiffness and pain in the bottom of her feet lasting around 1-2 hours in her wrists and hands. She continues to have pain and swelling in her fingers and wrists. She still has mild pain in elbows and shoulders. Infliximab was the first monoclonal antibody to human necrosis factor alpha (TNFa) developed for treating rheumatoid arthritis (RA). This chimeric antibody binds with high affinity to both soluble and trans-membrane TNF and is able to reduce synovial inflammation, bone resorption and cartilage degradation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infliximab have been met. Therefore, we decided that the Plan has to pre-approve infliximab (J1745).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultraviolet multidirectional light therapy system in 6
foot cabinet, includes bulbs/lamps, timer and eye protection (CPT Code E0694).
You asked the Plan to pre-approve the cabinet. You say that the cabinet is necessary. The Plan denied your
request. The Plan says the Medicare rules have not been met.
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 cabinet have not been met. Ultraviolet Cabinets are covered for
"selected patients with generalized intractable psoriasis". The member does not have generalized intractable
psoriasis. While this therapy may be helpful for the member's condition, Medicare only covers home
phototherapy for persons with generalized intractable psoriasis. Therefore, we decided that the Plan does not
have to pre-approve ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps,
timer and eye protection (CPT Code E0694).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxytocin, 30 mg.
You asked the Plan to pre-approve Oxytocin. You say that the medication is necessary The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
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 Oxytocin, 30 mg.
Benefits for Oxytocin may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466).
You asked the Plan to pre-approve the non-invasive home ventilator. You say that the enrollee has chronic respiratory failure with hypercapnia and COPD. You say that, without the use of the ventilator, the enrollee will have increased hospitalization readmissions and or early demise. You say that the enrollee qualifies for coverage and needs the non-invasive ventilator to be able to remain at home. The Plan denied your request. The Plan says the records do not show that the enrollee has ongoing breathing failure with a high carbon dioxide level in the blood, while she is awake and stable. The Plan says that the records do not show that the enrollee has tried another form of breathing support called Bi-PAP, at home.
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 non-invasive home ventilator. Our reviewer says that the non-invasive home ventilator is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has COPD with chronic hypercarbic respiratory failure and may benefit from BiPAP at home. But Medicare does not cover a ventilator when used as BiPAP. The enrollee has not tried and failed BiPAP while at home in a stable state. 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 non-invasive home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, preventive procedure, and
retreatment of previous root canal therapy provided on August 18, 2020, by an OON provider.
You asked the Plan to pay for the first intraoral periapical x-ray, preventive procedure, and retreatment of
previous root canal therapy. You say that you were not aware that this dentist was not participating with your
plan. You also say that they became a participating provider after you received these services. The Plan denied
your request. The Plan says these services were rendered by a non-participating provider. The Plan also says
that you were advised this provider was OON when you scheduled the appointment, and you paid in full for the
dental services.
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 items or services are not
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the first
intraoral periapical x-ray, preventive procedure, and retreatment of previous root canal therapy provided on
August 18, 2020, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four skilled nursing visits, one occupational therapy
visit, and eight home health aide visits.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the submitted records show that you do
not require additional skilled nursing or rehab services to effectively provide treatment, care, and/or services in
order to improve your condition, perform a maintenance program to maintain your condition, and/or prevent
deterioration. You are medically stable without any recent worsening of your chronic medical problems or
hospitalizations. Your care is mainly custodial in nature and your caregiver has demonstrated an understanding
of a home exercise program. The requested services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to p