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 you need rehab to get back to proper level of care. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 hypertensive urgency and frequent falls. Your medical conditions 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. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with a pulmonologist (99204) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that last year in January, you had heart surgery and since then, you have not been able to recover your oxygen levels and is currently using an oxygen tank. You also say that your primary care physician (PCP) submitted the authorization. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 items/services at issue in this appeal. The records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit with a pulmonologist (99204) to be provided by an out of network (OON) provider.
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 IRF services are medically necessary. The Plan
denied your request. The Plan says 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 there is not a reasonable expectation that this patient 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on April 1, 2021.
You asked the Plan to pay for a PET scan. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis.
The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate diagnosis code.
We looked at the file and Medicare rules. The billed diagnosis code, C50.911, malignant neoplasm of unspecified site of right female breast, is not listed as an appropriate code. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on April 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for hyperbaric oxygen therapy (99183) and debridement of skin (11042) provided on August 11, 2020, by an out of network (OON) provider.
You asked the Plan to pay for hyperbaric oxygen therapy and debridement of skin. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 hyperbaric oxygen therapy (99183) and debridement of skin (11042) provided on August 11, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for plastic surgery services provided to the enrollee on November 13, 2020.
You asked the Plan to pay for the services. You say that this claim is payable and no authorization was required. The Plan denied your request. The Plan says the claim has coding discrepancies and was not coded per Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate taxonomy. We find that the denied codes are not supported in the medical record. Specifically, the claim is missing the required rendering provider taxonomy. This code is needed to bill as a Medicare-eligible provider. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for plastic surgery services provided to the enrollee on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) procedure (43239) provided on February 25, 2021.
You asked the Plan to waive the copayment for an EGD procedure. You say that this was a diagnostic procedure not a surgical procedure. You also say that the Plan advised you that you did not have a copayment and would like reimbursement. 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 $125 copayment for outpatient hospital services and outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
You have been asked to pay a $125 copayment for an EGD procedure. The EOC confirms $125 is the required copayment for this service. An EGD procedure falls within the outpatient hospital services and outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 esophagogastroduodenoscopy (EGD) procedure (43239) provided on February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says there is only use of Lantus once daily.
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is only injecting insulin (Lantus) once daily. The enrollee has not been using insulin multiple times (3 or more) a day. The treatment does not require frequent adjustment on the basis of testing results. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre monitor for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the endoscopic retrograde cholangiopancreatography services coded 43274 provided on February 24, 2021.
You asked the Plan to pay for the endoscopic retrograde cholangiopancreatography services. You say that you feel this claim should be paid. 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 43274 is endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent.
We find that CPT code 43274 is not supported in the medical record. Specifically, the medical records did not include documentation of an endoscopic retrograde cholangiopancreatography (ERCP) for each stent with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage when performed, including sphincterotomy when performed; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the endoscopic retrograde cholangiopancreatography services have not been met. Therefore, we decided that the Plan does not have to pay for the endoscopic retrograde cholangiopancreatography services coded 43274 provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for an outpatient stent removal surgery (43276),
Medicare Part B drugs (J1610, J7120, J2704), diagnostic radiology (76000) and durable medical equipment
(DME) supplies, and devices provided on November 16, 2020.

You asked the Plan to waive the cost-share for outpatient surgery and services. You say that your cost share for
surgery should be $300, not the amount billed. The Plan denied your request. The Plan says the cost-share 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 $300
copayment for outpatient surgery and that additional cost-sharing may apply. Your contract with the Plan also
clearly says that you must pay a 20% coinsurance for Medicare Part B drugs, outpatient diagnostic tests and
DME related supplies.

You have been asked to pay a $276.24 copayment for outpatient surgery as well as a 20% coinsurance for
Medicare Part B drugs, outpatient diagnostic tests and DME supplies.

The EOC confirms $300 is the required copayment for outpatient surgery. The record shows that you have
been asked to pay a copayment of $276.24. This is lower than your required copayment responsibility of $300.

The allowed amount of the claim for Medicare Part B drugs is $85.55, resulting in a coinsurance obligation of
$17.10.

The allowed amount of the claim for outpatient diagnostic testing is $253.83, resulting in a coinsurance
obligation of $50.77.

The allowed amount of the claim for DME medical supplies is $2,786.23, resulting in a coinsurance obligation
of $557.25.

Your total cost share is $901.36 ($276.24 + $17.10 + $50.77+ $557.25 = $901.36). 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 cost-share for an outpatient stent removal surgery (43276), Medicare Part B drugs (J1610, J7120,
J2704), diagnostic radiology (76000) and durable medical equipment (DME) supplies, and devices provided on
November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visit provided on February 8, 2021 and the Medicare Part B drug and office visit provided on February 17, 2021.
You asked the Plan to waive the cost share for the specialist office visits and drug. You say that the second office visit was a continuation of the first office visit. The Plan denied your request. The Plan says you were charged the 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 a $35 copayment for specialist physician services and a 10% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a $35 copayment for each visit and 10% coinsurance for the Medicare Part B drug.
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 cost share for the specialist office visit provided on February 8, 2021 and the Medicare Part B drug and office visit provided on February 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you require additional mileage. The Plan denied your request. The Plan says that each one-way trip must not exceed 50 miles.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro orthosis (powered upper extremity range of motion assist device, L8702).

You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is experimental/investigational.

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 a MyoPro orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the MyoPro orthosis is not known to be effective, based on scientific evidence, professional standards, and expert opinion, in improving health outcomes in stroke patients. The MyoPro orthosis is not in widespread use based on scientific evidence. There is insufficient evidence in the scientific literature that the MyoPro orthosis will improve the long term outcomes for the enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MyoPro orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro orthosis (powered upper extremity range of motion assist device, L8702).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 12, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate primary diagnosis code. 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 laboratory services rendered on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a specialist (99214) and a drug infusion pump procedure (62370) provided on February 24, 2021, by an out of network (OON) provider.
You asked the Plan to pay for an office visit and a procedure. You say that you were unable to get authorization before the service was done. The Plan denied your request. The Plan says services were provided 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit with a specialist (99214) and a drug infusion pump procedure (62370) provided on February 24, 2021, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 14, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 14, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the deductible for an office visit provided on April 1, 2021.
You asked the Plan to waive the deductible for an office visit. You say that you are qualified for Medicaid assistance and should not owe anything. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that there is no medical deductible for physician/practitioner services, including doctor's office visits. The Plan says you must pay a $96 deductible for an office visit. Based on the Plan contract, however, you cannot be asked to pay a deductible for an office visit. Therefore, we decided that the Plan has to waive the deductible for an office visit provided on April 1, 2021.
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.