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

We decided that the Plan does not have to pay for a pharmacogenetic panel (81230, 81231, 81240, 81241, 81328) provided on January 4, 2021.
You asked the Plan to pay for a pharmacogenetic panel. You say that this is supported by the 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. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a
single procedural service, so 1 code must be submitted for the panel. We find that CPT codes 81230, 81231, 81240, 81241, and 81328 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with a single code. Based on this information, we decided that Medicare rules for coverage of a pharmacogenetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a pharmacogenetic panel (81230, 81231, 81240, 81241, 81328) provided on January 4, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided February 10, 2021 to
February 12, 2021.
You asked the Plan to pay for the acute inpatient level of care. You say that relevant documentation from the
medical record will show that the treatment provided was medically necessary and the care was provided in the
most appropriate setting. The Plan denied your request. The Plan says that the limited clinical information
received does not support the medical necessity for inpatient care after 02/09/2021.
The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollee's
condition can be managed safely only in the inpatient hospital setting.
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 pay for the acute inpatient level of care. Our
reviewer says that the requested items/services is considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee was admitted to the hospital on 2/4/21 with abdominal discomfort
and constipation. She had a history of COPD and hypertension. On admission, she was afebrile and tachycardic
to the 110-120 range. Her oxygen saturation was 90% on room air. Abdominal exam was negative. Abdominal
x-ray showed dilated large bowel loops. She was treated with IV fluids and an aggressive bowel regimen. The
progress notes from February 10, 2021 states that "the patient remains ALOC pending delivery of home O2".
The review has determined that the inpatient admission was appropriate.
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 acute inpatient level of care have not been met. Therefore, we decided that
the Plan has to pay for the acute inpatient hospital care provided February 10, 2021 to February 12, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider on October 1, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you saw your primary care physician. You say that you would like this copayment taken care of. 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 $50 copayment for physician/practitioner services/specialist. You have been asked to pay a $50 copayment for an office visit. These services were provided by a specialist; therefore, the correct copayment has been applied.An office visit falls within the physician/practitioner
services/specialist 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 office visit provided by a participating provider on October 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the brain you had on March 24, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you had to wait for hours for this test and the music in the MRI machine malfunctioned. You said that because you had a poor experience, you should not have to pay a copayment. The Plan denied your request. The Plan says that you were charged this copayment 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 $225 copayment for diagnostic radiology services. You have been asked to pay a $225 copayment for the MRI. The MRI falls within the diagnostic radiology services benefit category. This copayment applies regardless of your satisfaction with the experience. 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 magnetic resonance imaging (MRI) of the brain you had on March 24, 2021.
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. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 rib fractures after a fall. 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive,
multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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 IRF admission and services.
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 LTACH admission is medically necessary. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's medical needs are being met in the current acute 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 that there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 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: 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 SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your rehabilitation needs can safely be received at a different setting.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Nucala infusion you received on March 17, 2020.
You asked the Plan to waive the coinsurance for the Nucala infusion. You say that you cannot afford this medication. The Plan denied your request. The Plan says you were charged this 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 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Nucala infusion. The Nucala infusion falls within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Nucala infusion you received on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for dermatology services you received on March 24, 2021.
You asked the Plan to waive the copayment for the dermatology services. You say that there should not be a copayment for this since it was just a follow-up. You also said that because you only saw the physician's assistant, you should not have to pay a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($42.20) is less than your copayment obligation, you are responsible for the full allowed 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 $45 copayment for services received from a specialist physician/practitioner.
You have been asked to pay a $45 copayment for the dermatology services. This copayment applies regardless of what type of provider you see at the dermatology office. It also applies even for follow-up visits. 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 dermatology services you received on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on April 16, 2021.
You asked the Plan to pay for foot orthotics. You say that you have severe Plantar Fasciitis. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the face down positioning cushion rendered on November 12, 2020.
You asked the Plan to pay for these services. You say that you needed the item after surgery. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a face down positioning cushion is statutorily non-covered. We looked at the file and Medicare rules. The services at issue are a face down positioning cushion. This item is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the face down positioning cushion rendered on November 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied for the outpatient mental health visit you had on March 2, 2021.
You asked the Plan to waive the deductible applied for the outpatient mental health visit. You say that you shouldn't have to pay a deductible because this provider didn't do anything for you. The Plan denied your request. The Plan says you had not yet met your deductible at the time of these services.
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 a $750 deductible which applies to outpatient mental health services. You had not yet met your deductible at the time of the outpatient mental health services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient mental health services. This deductible applies regardless of your satisfaction with the services received. This cost sharing is a contractual obligation that had not been met at the time the outpatient mental health visit was received on March 2, 2021. Therefore, we decided that the Plan does not have to waive the deductible applied for the outpatient mental health visit you had on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested monitor. The Plan denied your request. The Plan says the required criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit (99213) and the Omidria
solution injections (J1097 x 2) provided from March 3, 2021, through March 18, 2021.

You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the
services provided.

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 $45
copayment for each Medicare-covered visit with a specialist. Additionally, enrollees pay a 20% coinsurance for
each Medicare-covered Part B drug.

You have been asked to pay $207.74 which includes a $45 copayment for the Medicare-covered specialist visit
and $162.74 (Plan allowed amount of $406.84 x 20% coinsurance=$81.37 x 2) for the Medicare-covered Part B
drugs injections provided. 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 office visit (99213) and
the Omidria solution injections (J1097 x 2) provided from March 3, 2021, through March 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. 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 you are a 63 year old male with dementia who
went to the emergency room for a seizure on August 27, 2021. In this case, there are no documented daily
skilled nursing needs. At the current level of function and inability to participate with dementia, you do not
require daily skilled therapies in an inpatient setting. Your care needs may need to be addressed in a long-term
care facility.
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 admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hypoglossal nerve stimulation device.
You asked the Plan to pre-approve the requested device. You say that the denial is preventing access to valuable medical treatment. The Plan denied your request. The Plan says Medicare criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that hypoglossal nerve stimulation is only covered under certain medical indications.
We looked at the file and Medicare rules. We find that the coverage criteria have not been met. Specifically, the records do not indicate an AHI level between 15-65 events per hour. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a hypoglossal nerve stimulation device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99215) provided on June 22, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that the patient has chronic kidney disease, and the visit was needed to evaluate the member's kidney function. You also say 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 records show this was a follow-up visit. 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 (99215) provided on June 22, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a custom abutment (D6057-30), and an abutment supported crown (D6058-30) provided on April 26, 2021.
You asked the Plan to pay for a custom abutment, and an abutment supported crown. You say that the services should be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 pay for a custom abutment (D6057-30), and an abutment supported crown (D6058-30) provided on April 26, 2021.