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

We decided that the Plan does not have to pre-approve a segmented, calibrated gradient pneumatic compression device (E0652).
You asked the Plan to pre-approve the pneumatic compression device. You say that you would like reconsideration because the member's condition rules out the use of a simple leg pump. The Plan denied your request. The Plan says the member has not had a trial with E0650 or E0651.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the pneumatic compression device. Our reviewer says that the criteria for an E0652 pneumatic compression device has not been met. Our physician reviewer found the documentation does not indicate that the member has lymphedema extending onto the chest, trunk and/or abdomen. The documentation reveals the member is responding to lymphedema/compression therapy. The member has not tried and failed an E0650 or E0651. 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 pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmented, calibrated gradient pneumatic compression device (E0652).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to waive the copayment for the SNF and inpatient hospital services provided on March 11, 2021, through April 9, 2021.

You asked the Plan to waive the copayment for the SNF and inpatient hospital services. You say that you would like reconsideration because you were not satisfied with the care you received in the SNF and were admitted to the hospital due to the SNF's negligence. The Plan denied your request. The Plan says that the copayments have been applied correctly.

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 enrollees must pay a $0 copayment for days 1-20 in an SNF. The contract also says that there is a $200 copayment for days 1-6 for inpatient hospital services. 

The Plan says you must pay $0 for days 1-20 in an SNF and $200 for days 1-6 in an inpatient hospital. Based on the Plan contract, however, you cannot be asked to pay more than $0 for days 1-20 in an SNF and $200 for days 1-6 in an inpatient hospital. You have been asked to pay a $1200 copayment for SNF services and a $970 copayment for the inpatient hospital services. This cost sharing amount has not been applied appropriately. Therefore, we decided that the Plan has to waive the copayment for the SNF and inpatient hospital services provided on March 11, 2021, through April 9, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 while the documentation supports that the enrollee may benefit from skilled therapy services, it does not support that these services are medically reasonable and necessary on a daily basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee can reasonably transition to a home education program with the currently
total number of approved visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 visits. Our reviewer says that the
requested visits are not medically reasonable or necessary. Our physician reviewer found based on the medical
records provided there is no documentation that skilled therapy services are required to effectively provide
treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a
maintenance program to maintain the enrollee's level of function and/or prevent deterioration. Nothing in the
provided records clarifies why the twenty visits that have already been approved are inadequate to treat the
enrollee's condition and to transition her to a home exercise 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 the visits have not been met. Therefore, we decided that the Plan does not have
to pre-approve home health physical therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for special anesthesia service provided on February 24, 2021.
You asked the Plan to pay for special anesthesia service (99100). You say that the Plan should pay this claim.
The Plan denied your request. The Plan says payment for this procedure code is always bundled into payment
for other services and no separate payment is made per Medicare.
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, we have confirmed that code special
anesthesia service (99100) has a status code of B (Bundled Code) and cannot be paid as billed. This code
cannot be paid as a separate line item. Payment for covered services are subsumed by the payment for the
services to which they are incident. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for special anesthesia service provided on February
24, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99213) provided on March 25, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you had corneal transplants and are required to have an annual eye exam with your surgeon. You also say that you cannot see any other provider as this provider performed your surgery and knows what he did. The Plan denied your request. The Plan says the copayment you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for physician/practitioner services, including doctor's office visits with a specialist.
You have been asked to pay a $35 copayment for an office visit with a specialist. The records show you had a medical eye exam with a specialist. The EOC confirms $35 is the required copayment for this service. An office visit with a specialist falls within the physician/practitioner services, including doctor's office visits with a 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 with a specialist (99213) provided on March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided safely in a less intensive setting of care, for example, at a skilled nursing facility or home with supervision and home health.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 these services are medically necessary. The Plan denied your request. The Plan says that your needs can be met at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on August 28, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for a drug test. You say that prior authorization was not obtained for these services. The Plan denied your request. The Plan says the correct copayment has been applied.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 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 a drug test provided on August 28, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral nutrition supplements.

You asked the Plan to pre-approve these services. You say that your doctor suggested this would work for you. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 

The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve enteral nutrition supplements.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that this inpatient care is medically necessary The Plan denied your request. The Plan says that inpatient care is not medically necessary in this case.
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 midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights 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 payment are met in this case. Our physician reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably expects that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 the 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the column chromatography rendered on August 17, 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 82542 is not separately payable.

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 G0481 (definitive drug testing, 8-14 drug classes) and 82542 (column chromatography). Code 82542 is a column II code with a modifier indicator of 1 when billed with column I code G0481. Code 82542 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the column chromatography rendered on August 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance image guided high intensity focused ultrasound (MRgFUS).
You asked the Plan to pre-approve a MRgFUS. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that MRgFUS unilateral thalamotomy is considered medically reasonable and necessary in patients that meet specific criteria. 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 MRgFUS. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case you do not meet the
requirements of the LCD for coverage of this service. Notably you don't have essential tremor (ET) which is the only indication for which the LCD covers this service. As such said service would not be eligible for coverage. 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 MRgFUS have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance image guided high intensity focused ultrasound (MRgFUS).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laboratory services (36415, 82728, 83540, 83550, 85025) and the therapeutic phlebotomy (99195) provided on December 23, 2020.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have 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 $10 copayment for laboratory services and a $240 copayment for each outpatient hospital facility visit for outpatient surgery.
You have been asked to pay $174.97 which includes a $10 copayment for the laboratory services provided and the Plan allowed amount of $164.97 for the outpatient surgery provided, which is less than the applicable copayment for this 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 copayments for the laboratory services (36415, 82728, 83540, 83550, 85025) and the therapeutic phlebotomy (99195) provided on December 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) care provided from February 2, 2021, through March 4, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day, for days 1-20, per admission and a $160 copayment per day, for days 21-100, per admission for skilled nursing facility care.
The enrollee has been asked to pay $1,600 ($160 copayment x 10 days) for the skilled nursing facility care provided. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) care provided from February 2, 2021, through March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 10, 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 were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on September 22, 2020.
You asked the Plan to waive the copayment for an ultrasound. 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 $110 copayment for outpatient diagnostic tests/radiological diagnostic services. You have been asked to pay $97.02 which is less than your copayment amount of $110 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests/radiological diagnostic 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 copayment for an ultrasound provided by a participating
provider on September 22, 2020.