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 for the enrollee.You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for repair of humeral fracture. She required blood transfusion after surgery. Her medical conditions are now stable. There are no complicated nursing or wound care needs. There is no documentation that the enrollee requires management three days a week by a rehabilitation physician.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the program provided in an IRF.Medicare coverage criteria are not met. 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided July 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 the drug testing services provided July 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids providedon February 14, 2019.You asked the Plan to pay for the hearing aids. You say that you took possession of the hearing aids on February 14, 2019, but the purchase did not become final until March 14, 2019 because you had the hearing aids on a 30-day approval agreement. The Plan denied your request. The Plan says you must submit your Part C (medical) claimto us within 12 months of the date you received the service.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the hearing aids was not filed until March 13, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for hearing aids provided on February 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary for anemia in chronic
kidney disease. The Plan denied your request. The Plan says the accepted use of this drug requires adequate
iron stores.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the review indicates
that the Plan requires a trial of Retacrit before they will approve the requested drug. In this case, the patient has
not tried and failed the required drug(s). There is no documentation provided indicating that the the Plan's
required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.
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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Epogen for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay foran additional 30 minutes of critical care services (99292) provided on November 12, 2019 through November 14, 2019.You asked the Plan to pay forthe additional critical care services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plansays the records do not support that an additional 30 minutes of critical care services was performed in addition to the first 30-74 minutes of a critical care evaluation and management service.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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).We find that CPT code 99292 is not supported in the record. Specifically, the record indicates that critical care services were rendered for 45 minutes total onthe billed dates of service. Based on this information, we decided that Medicare rules for coverage of the additional critical care services have not been met.Therefore, we decided that the Plan does not have to pay foran additional 30 minutes of critical care services (99292) provided on November 12, 2019 through November 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve colored drive wheel inserts for the enrollee.You asked the Plan to pre-approve colored drive wheel inserts. The Plan denied your request. The Plan says that drive wheel inserts are not required for the power wheelchair to function but are more for customization of the appearance of the wheelchair.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 pre-approve colored drive wheel inserts for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Orthovisc injections (20610, J7324).You asked the Plan to pre-approve Orthovisc injections. You say that the enrollee has previously received Orthovisc injections.The Plan denied your request. The Plan says that there are currently no clinical indications for this technology.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 Orthovisc injections. Our reviewer says that the documentation supports that Orthovisc injections are medically reasonable and necessary and safe and effective for treatment of this enrollee's severe right knee osteoarthritis. Our physician reviewer found the enrollee presents with recurrent severe right knee pain with associated swelling and clicking. Functional limitations are noted in activities of daily living. Clinical exam findings have been consistent with imaging evidence of bone-on-bone right knee lateral compartment osteoarthritis. She has failed to improve with conservative treatment, including activity modification, medications, cortisone injection and bracing. She underwent prior Orthovisc injections with long-term pain reduction to minimal symptoms and improvement in activities of daily living. Evidence based medical peer-reviewed literature supports the use of visco supplementation injections for the treatment of pain in patients with osteoarthritis of the knee, and indicated that repeat injections are effective in delaying time to total knee replacement for patients with knee osteoarthritis which failed conservative treatment. Repeat Orthovisc injections are reasonably indicated for treatment of this enrollee's knee pain given the failure of comprehensive conservative treatment, worsening pain and functional limitations, and significant previous benefit with these injections.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc injections have been met.Therefore, we decided that the Plan has to pre-approve Orthovisc injections (20610, J7324).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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy evaluation services (97165) and self-care/home management training (97535) provided on January 27, 2020.You asked the Plan to pay for the occupational therapy evaluation and self-care/home management training.You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the diagnosis codes submitted on the claim are mismatched.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy evaluation and self-care/home management training have not been met. Specifically, this claim has been submitted with two separate diagnosis codes to indicate left and right. There is a more appropriate bilateral diagnosis code.Therefore, we decided that the Plan does nothave to pay foroccupational therapy evaluation services (97165) and self-care/home management training (97535) provided on January 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNFcare from August 1, 2019 through August 31, 2019.You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received SNF care from August 1, 2019 through August 31, 2019. Your EOC states that enrollees must pay a $0 copayment per day, days 1-20 and a $172 copayment per day, days 21-100 for SNF care. Therefore, you are asked to pay a $1,892 copayment for the SNF care. 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 SNF care from August 1, 2019 through August 31, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound examination provided on February 4, 2020.
You asked the Plan to waive the copayment for ultrasound. You say that you are unable to pay this amount due to financial hardship. The Plan denied your request. The Plan says the copayment amount 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 $100 copayment for ultrasound. You have been asked to pay $100 copayment for ultrasound. ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound examination provided on February 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forintracardiac catheter ablation (93650) provided on March 9, 2020.You asked the Plan to pay forintracardiac catheter ablation. You say that these services were provided bydifferent providers with different specialties.The Plan denied your request. The Plan says this service is included in the global surgery package.The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for procedures includes payment for the above listedservices related to the surgery when furnished by the physician who performs the surgery.We looked at the file and Medicare rules. The records show that surgical procedure 33249, which has a global period of 90 days, was performed on February 17, 2020. This procedure and the service at issue were billed with the same rendering provider. Therefore, the service at issue is included in the global surgical package. Based on this information, we decided that Medicare rules for coverage of intracardiac catheter ablation have not been met.Therefore, we decided that the Plan does not have to pay forintracardiac catheter ablation (93650) provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit provided on January 21, 2020.You asked the Plan to waive the copayment for the office visit. You say that this was your annual physical exam and there should be no copayment. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.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. There were no medical records or claim form with the diagnosis codes submitted to support that services in addition to an annual wellness visit were performed. Therefore, we decided that the Plan has to waive the copayment for the office visit provided on January 21, 2020.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for supplies provided on February 7, 2020 and March 26, 2020.You asked the Plan to waive the coinsurance for the supplies. You say that you have never had a member responsibility for your supplies.The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received supplies provided on February 7, 2020 and March 26, 2020. Your EOC states that enrollees must pay 20% coinsurance for prosthetic devices and medical supplies. You are asked to pay 20% coinsurance for the supplies. 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 supplies provided on February 7, 2020 and March 26, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on February 12, 2020.
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing because it was medically necessary. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that procedure code 0005U is covered by Medicare for date of service February 12, 2020 and may be used to bill the EPI test. We looked at the file and Medicare rules. The Plan denied payment on the basis that testing code 0005U is not covered and did not provide any other rationale to support a denial of payment. You billed the EPI test using procedure code 0005U. This code is covered by Medicare for billing of the EPI test for date of service February 12, 2020. Therefore, we decided that the Plan has to pay for genetic testing provided on February 12, 2020.
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 pre-approveTadalafil for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrollee needs this for prostate issues.The Plan denied your request. The Plan says that this is not covered under 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-approveTadalafil for the enrollee.Benefits for this drugmaybe available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit (99281) provided February 8, 2020.You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be waived.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 $100 copayment for Emergency Care. You have been asked to pay the allowable amount of $87.87 for the emergency room visit. The emergency room visit falls within the Emergency Care benefit category. The allowable amount is less than the $100 noted in the Evidence of Coverage. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharingis 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 Emergency Room Visit (99281) provided February 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 4, 2019.You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required the remain in the operating room through the length of the procedure.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.`The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea dental bridge for teeth #7-9.You asked the Plan to pre-approvea dental bridge. You say that you slipped and fell, and your tooth fell out.The Plan denied your request. The Plan says the requested services are not covered under your dental plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea dental bridge for teeth #7-9.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI scan. You asked the Plan to pre-approve an MRI. 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 MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI. Our reviewer says that the documentation does not support that the requested MRI is medically reasonable or necessary. Our physician reviewer found the enrollee has shoulder pain. The documentation does not show adequate conservative measures for shoulder pain. There is no recent trial of physical therapy. Therefore, the enrollee does not meet criteria for the requested MRI at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI scan.