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 the records provided support the need for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. 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 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 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 require physical therapy and occupational therapy services but does not require an intensive inpatient rehabilitation therapy program. Care at the skilled nursing facility level appears to be appropriate in this case. 

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: 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 it is not safe for the enrollee to go home. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needs can safely be met at a lower level.

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 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 fever, rash and a urinary tract infection. The enrollee's medical problems are stable. 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 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 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MolDX panel coded 81286, 81404, 81407, 81408, and 81479.

You asked the Plan to pay for the MolDX panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 the MolDX panel is not supported in the medical record. Specifically, this service should be billed with code 81479. In addition, the appropriate DEX-Z code should be entered adjacent in the comment/narrative field for the test. Based on this information, we decided that Medicare rules for coverage of the MolDX panel have not been met. Therefore, we decided that the Plan does not have to pay for the MolDX panel coded 81286, 81404, 81407, 81408, and 81479.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost-share for surgical eye injection services (67028) and Bevacizumab injections (C9257).

You asked the Plan to reduce the cost-share for ophthalmic surgery and drug services. You say that you did not know the cost-share amounts changed from 2019 to 2020. You want to pay the amounts you would have owed in 2019. The Plan denied your request. The Plan says this change was included in the annual notice of changes for your Plan. The claims were billed 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 surgical services provided at an outpatient hospital facility and a 20% coinsurance for Medicare Part B drugs.

You have been asked to pay a $300 copayment for surgical services provided at an outpatient hospital facility and a 20% coinsurance for Medicare Part B drugs. 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 reduce the cost-share for surgical eye injection services (67028) and Bevacizumab injections (C9257).

Your complaint about the Plan's choice to change their benefits from 2019 and your feelings that you were not properly notified of these changes is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit.

You asked the Plan to waive the copayment for the office visit. You say that all charges should be covered in full as part of the pre-operation testing. 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 $15 copayment per visit for an in-network PCP and a $15 copayment per visit for an in-network specialist office visit.

You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for a pre-operative service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided by a participating provider.

You asked the Plan to waive the copayment for cataract surgery. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for outpatient surgery/outpatient hospital facility.

You have been asked to pay a $400 copayment for cataract surgery. These services were provided at an outpatient hospital facility; therefore, the correct copayment has been applied. Cataract surgery falls within the outpatient surgery/outpatient hospital facility 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 cataract surgery provided by a participating provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider.

You asked the Plan to waive the copayment for an emergency room visit. You say that you don't believe that you needed to go to the emergency room. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care/emergency room visit.

You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit was provided, the correct copayment has been applied. An emergency room visit falls within the emergency care/emergency room visit 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 emergency room visit provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee has already been accepted in the new facility and meets all the requirements to be transported. You say that the enrollee needs to be transferred to be weaned off of the ventilator. The Plan denied your request. The Plan says the enrollee is not stable enough to be transferred to an LTACH at this time. The Plan says that the enrollee has not completed the full course of care at the hospital and needs to stay there until better.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The does not enrollee require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic angiography, abdomen and pelvis.

You asked the Plan to pre-approve a CT angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing (74174). You say that the enrollee needs the CT angiography. The Plan denied your request. The Plan says the procedure is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing (74174). Our reviewer says that the service is not medically necessary. Our physician reviewer found Bosniak category I and II renal cysts, do not require further imaging or follow-up unless symptoms such as hematuria or pain develop. The cysts described in the medical records provided have been stable by ultrasound since February 2, 2018, are consistent with Bosniak category I and II, and are asymptomatic. As such, CT imaging is 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 a CT angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing (74174) have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic angiography, abdomen and pelvis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that it is medically appropriate for the enrollee to complete here treatment at an LTACH due to multiple hospital re-admissions, failed outpatient treatment of complex wounds, and infectious disease evaluation. The Plan denied your request. The Plan says the requirements for approval of LTACH care have not been met. The Plan says that the enrollee can safely receive the care needed in another setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present setting. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET/CT scan.

You asked the Plan to pre-approve a PET/CT scan. You say that the requested PET/CT scan is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested PET/CT scan.

The Plan must follow Medicare rules. Medicare rules say that PET scans 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 as PET/CT scan. Our reviewer says that the enrollee does not meet criteria for the requested PET/CT scan. Our physician reviewer found the enrollee has a history of newly diagnosed melanoma on biopsy. Per NCD 220.6.17, the requested PET/CT scan is not covered for initial staging of regional nodes. 

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 PET/CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET/CT scan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing.

You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The cardiovascular risk assessment testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the change of cystostomy tube (51705).

You asked the Plan to waive the copayment for the change of cystostomy tube. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgery on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 surgery.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a change of cystostomy tube. You have been asked to pay a $250 copayment for the change of cystostomy tube. The change of cystostomy tube falls within the Outpatient surgery 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 the change of cystostomy tube (51705).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve surgical reconstruction of left mandible.

You asked the Plan to pre-approve surgical reconstruction of left mandible. You say that the requested surgical reconstruction of left mandible is medically necessary. The Plan denied your request. The Plan says that the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 surgical reconstruction of left mandible. Our reviewer says that the requested surgical reconstruction of left mandible is medically necessary. Our physician reviewer found the enrollee is with pain due to an inflammatory condition of the jaws, severe atrophy of the mandible, chronic moderate periodontitis, and disorders of the teeth and supporting structure. The enrollee has atrophy of the alveolar partially edentulous ridge in the left posterior mandible. The enrollee has problems with mastication and swallowing.

The requested service is for the treatment of a medical condition. Failure to treat this medical condition has the potential to result in severe adverse conditions. Medicare covers medically necessary surgery related to the jaw. It is expected that the enrollee will benefit from surgical reconstruction of the left mandible.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgical reconstruction of left mandible have been met. Therefore, we decided that the Plan has to pre-approve surgical reconstruction of left mandible.

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 pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on September 3, 2020.

You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.

The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, medical records do not support a prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was performed. The information submitted does not confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on September 3, 2020.