Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee will not benefit from at least 3 hours therapy a day.
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 physician reviewer found that the enrollee was admitted to the acute hospital for hyperglycemia, urinary tract infection, and chronic diarrhea.
His medical conditions are stable. There are no complex nursing needs. There is not a reasonable expectation that he 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require an
intensive, complex, multidisciplinary approach to daily therapy.
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 physician reviewer found
that you were admitted to the acute care hospital for surgical treatment of a hip fracture after a fall. Your
medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple
therapies in an intensive rehabilitation therapy program. You do require physical and occupational therapy but
there is no documented need for an intensive rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression wraps identified with code A6545.
You asked the Plan to pre-approve the compression wraps. You say that you are appealing because the office is not open every day and the information was not received until the due date had passed. The Plan denied your request. The Plan says the enrollee does not have any ulcers or wounds on the lower extremities and does not meet the Medicare criteria.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve gradient compression wraps identified with code A6545.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81407, 81408, 81439) provided on August
10, 2020.
You asked the Plan to pay for genetic testing. You say that this is supported in the medical records. The Plan
denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. To report a CGP service, test providers should
use CPT code 81479 at this time.
We find that CPT codes 81407, 81408, and 81439 are not supported in the medical record. Specifically, the
record shows these codes were used to report a CGP service, which should be reported with 81479. Based on
this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore,
we decided that the Plan does not have to pay for genetic testing (81407, 81408, 81439) provided on August
10, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for SNF care is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the enrollee meets the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee requires daily skilled therapy services on an inpatient basis in a Skilled Nursing Facility (SNF) 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for
SNF care. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity
guidelines for coverage of SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral
medications, had stable vital signs, and clear lungs. The enrollee was alert with confusion. The enrollee
received physical therapy in the acute hospital. The enrollee was at a supervision to contact guard to minimal
assist level with functional mobility, including gait to 80 feet with a rolling walker. There are no identifiable
skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a
daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient
basis in a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided
from September 24, 2020, to October 29, 2020.

You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you were told
repeatedly that you would not owe a copayment. 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 $30
copayment for outpatient rehabilitation services.

You received outpatient rehabilitation services from September 24, 2020, to October 29, 2020, for a total of 11
services. Therefore, you are responsible to pay a $30 copayment per each visit. The total amount you owe is:
$30 (copayment) x 11 (outpatient rehabilitation visits) = $330.

You have been asked to pay the total copayment amount of $330 for outpatient rehabilitation services.
Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 copayments for outpatient rehabilitation services provided from September 24,
2020, to October 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient therapy services rendered on September 30, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 97530 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, there is no documentation of therapeutic activities with direct patient contact for 15 minutes. 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 outpatient therapy services rendered on September 30, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) and testing services rendered on October 4, 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 services are not covered.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 93042 (rhythm ECG) and 93010 (ECG). Code 93042 is a column II code with a modifier indicator of 1 when billed with column I code 93010. Code 93042 was not billed with an appropriate modifier to allow for separate payment.The rules say that claims must be billed with the most precise diagnosis code.

The rules say that claims must be billed with the most precise diagnosis code. 

The file shows that the claim for codes 99285 (ER visit) and 93010 (ECG) were not billed with a valid primary diagnosis code. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) and testing services rendered on October 4, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnight. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnight or more.

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnight.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient hospital care.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET of the whole body (78813).
You asked the Plan to pre-approve the PET. You say that you would like reconsideration because this is a new diagnosis and the requested PET is medically necessary. The Plan denied your request. The Plan says CMS continues to nationally non-cover initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate.
The Plan must follow Medicare rules. Medicare rules say that CMS continues to nationally non-cover initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET have not been met. Specifically, CMS does not cover PET for the initial treatment strategy for the member's condition. Therefore, we decided that the Plan does not have to pre-approve PET of the whole body (78813).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for blepharoplasty provided on January 15, 2021.
You asked the Plan to waive the copayment for blepharoplasty. You say that you were not informed that you would owe a copayment and you feel that the charges are excessive. 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 $325 copayment for outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers. You received blepharoplasty on January 15, 2021, at an ambulatory surgical center. Blepharoplasty is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $325 copayment.
You have been asked to pay a $325 copayment for blepharoplasty. Blepharoplasty falls within the 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 blepharoplasty provided on January 15, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on December 17, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denied coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on December 17, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider from
January 14, 2021, to January 25, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider from January 14, 2021, to January 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF care.

You asked the Plan to pre-approve SNF care. You say that you feel unable to return safely yet to your own home. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 that you do not require any skilled nursing or rehab services on a daily basis. You are not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). You do not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you do not require any skilled services on an inpatient basis at a SNF level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) thorax (71250).

You asked the Plan to pre-approve the CT scan. You say that you are having worsening shortness of breath and feels like there is a lump in your throat when you swallow. You have COPD and wants the CT scan to make sure you do not have lung cancer. The Plan denied your request. The Plan says the information received does not support the medical necessary criteria for the requested CT scan.

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 the CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee indicates that the enrollee has chronic obstructive pulmonary disease, is a smoker, and has a history of pulmonary nodules. The enrollee has had several CT scans demonstrating stability in the nodules over a two-year period. The medical record does not indicate any other rationale for the study. The medical record does not support the medical necessity or reasonableness, as defined by Medicare rules, of the requested service.

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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) thorax (71250).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the dispensing plan meets for Part D coverage.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).

Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.