Persius/hicric huggingface dataset:
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 could be received 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR, HHS, LTC).

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 pay for the evaluation and management services provided on May 10, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says valid proof that this claim was received in a timely manner was not submitted.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a valid claim for the services provided was not filed until August 4, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the evaluation and management services provided on May 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve the CGM. You say that this device is what you require in order to manage your diabetes. The Plan denied your request. The Plan says the evidence available does not support that CGM criteria are met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. The record submitted by your physician does not directly address diabetes management, but indicates that insulin is ordered for use only once per day. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a tissue exam (CPT 88305) provided to the enrollee on October 12, 2020.
You asked the Plan to pay for the exam. You say that the claim is being treated as a duplicate when in fact it is a separate service. 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. In this case, the CPT Code Manual definition of code 88305 is "Level IV - Surgical pathology, gross and microscopic examination." We asked our coding 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 exam. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the medical records provide do indicate two different specimens from two different sites on two slides were prepared on October 21, 2020. However, these two slides were not billed to the health plan at the same time, so the provider billed CPT 88305 on two different claims. This is not the appropriate way to bill 2 services of 88305 with the expectation of separate reimbursement. Even if the 2 separate specimens/services are billed on 2 separate claims, they were performed on the same date of service and the second billing of 88305 requires a 59 modifier to be appended in order to be considered for reimbursement. The more appropriate resolution would be to do a corrected claim for the original paid claim of 88305. As a result of incorrect billing, the 88305 being denied is not eligible for reimbursement consideration. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the exam have not been met. Therefore, we decided that the Plan does not have to pay for a tissue exam (CPT 88305) provided to the enrollee on October 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 5, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary. The Plan denied your request. The Plan says no reimbursement can be made for items that were the result of an unsolicited phone call.
The Plan must follow Medicare rules. Medicare rules say that the provider of durable medical equipment may not contact the enrollee by phone unless written permission by the enrollee has been given. We looked at the file and Medicare rules. In this case, the Plan has attested that the enrollee was contacted via an unsolicited phone call regarding the provision of the item at issue. Based on this information, we decided that Medicare rules for coverage of the knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings of four or more teeth per quadrant and one periodontal scaling and root planing of one to three teeth per quadrant provided on December 8, 2020.
You asked the Plan to pay for the scalings and planings. You say that you had not met the calendar year maximum. The Plan denied your request. The Plan says your calendar year maximum had been reached.
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 Plan offers a $750 combined allowance for supplemental preventive and comprehensive services every year. The Plan contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim for the December 8, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two periodontal scalings and root planings of four or more teeth per quadrant and one periodontal scaling and root planing of one to three teeth per quadrant provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Orthovisc is only covered for certain indications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Orthovisc. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee has osteoarthritis of the right knee. The enrollee has had prior
viscosupplementation with different medications but has not achieved significant pain relief. The lack of
significant pain relief from prior viscosupplementation does not meet the criteria for another trial. Therefore,
the enrollee does not meet criteria for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve Orthovisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate maxillary denture.

You asked the Plan to pay for the immediate maxillary denture. You say that you would like some help paying for this service because you are on a limited income. The Plan denied your request. The Plan says your dental maximum had been met.

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 Plan offers a $2,000 annual dental benefit maximum. The record shows that you met the annual maximum benefit and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the immediate maxillary denture.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Truxima 10mg/ml solution for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that the dosing regimen needs to be clarified.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has relapsed chronic lymphocytic leukemia (CLL). Rituximab in combination with venetoclax is a standard of care and FDA approved/supported by major drug compendia for this indication. The service is reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have been met. Therefore, we decided that the Plan has to pre-approve Truxima 10mg/ml solution for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered.

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 claim was 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 drug testing rendered.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinary tract and antibiotic genetic testing services.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says molecular genetic screening testing is not a Medicare benefit for the diagnoses listed.

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 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 urinary tract and antibiotic genetic testing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397)
provided October 5, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the requested items were
medically necessary. The Plan denied your request. The Plan says the records do not demonstrate that the
prescribing physician ever saw the member.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to
the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our
reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer
found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient
credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately
payable when the base item is not covered.
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 knee orthosis and suspension sleeve have not been met. Therefore, we
decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397)
provided October 5, 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 need to be admitted to a SNF because of incidents with your lines and catheter. The Plan denied your request. The Plan says that the required supervision for dementia does not require skilled nursing.
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 service is medically necessary. Our physician reviewer found based on the documentation provided the enrollee qualifies for SNF coverage. The enrollee does have documented skilled nursing needs, as is receiving IV antibiotics four times per day. The enrollee does not have documented skilled therapy needs. 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility admission.
You asked the Plan to pre-approve a SNF admission. You say that the enrollee needs skilled nursing facility services. The Plan denied your request. The Plan says the enrollee's therapy services can be managed safely with home health services.
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 a SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, it is my opinion that the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to ADLs given the month-old humerus fracture. The enrollee's care needs, as a practical matter, can be provided at a lower level of care (ex. home, AL, LTC).
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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because the surgery was necessary. 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 $395 copayment for days 1-4 for inpatient hospital care.

You have been asked to pay a $395 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction (D7140), the placement of an implant body (D6010) for tooth # 5, the unspecified implant procedure (D6199), and the bone graft at time of implant placement (D6104).

You asked the Plan to pre-approve the implant services. You say that the plan did not pay anything. You say that the insurance only paid $3.50. You say that you received a bill for $3,165. You also say that the insurance is not paying enough. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that 1 placement of an implant body is covered every 5 years per patients, per quadrant. The Plan says that the frequency limit for this service has been exceeded. The Plan says that extractions are covered at 50% of the allowed amount after the $100 deductible has been met. The Plan also says that unspecified implant procedure and bone graft at time of implant placement are not listed as covered services.

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 and implants are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for an implant for tooth # 6 that you received on this date of service. Teeth # 5 and 6 are in the same quadrant, thus exceeding the limit of one per patient, per quadrant in 5 years. Extractions are listed as covered at 50% of the allowed amount after the $100 deductible has been met. The record shows that the Plan applied the $28.50 copayment correctly. Additionally, unspecified implant procedure and bone graft at time of implant placement are not listed as covered services.

Therefore, we decided that the Plan does not have to pre-approve the extraction (D7140), the placement of an implant body (D6010) for tooth # 5, the unspecified implant procedure (D6199), and the bone graft at time of implant placement (D6104).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. 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 medically necessary.

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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department (ED) with a nosebleed. The enrollee was advised to consult ears, nose and throat (ENT) if the bleeding persists. The enrollee's condition stabilized and the enrollee was discharged home. The record does not show 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 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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.