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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare criteria for IRF care are not met. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 medical records indicate you are generally medically stable. The documentation does not support that you have complex medical issues that require acute rehab nursing care or monitoring by an inpatient PMR physician three times per week. The documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Medicare coverage criteria are not met. 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 a group 3 power mobility device with a single power option (K0857) and accessories (E2300, E2361, E1028, E2310, K0108, E0995). You asked the Plan to pre-approve the Power chair and accessories.. You say that the group 3 power mobility device with the seat elevator is medically necessary. The Plan denied your request. The Plan says the item does not meet coverage criteria. The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. While the enrollee may meet these requirements for the Group 3 power mobility device, only a single power option is requested in this case. Since the single power option (a Seat Elevation Feature, E2300) is statutorily non-covered, the related features are non-covered. There is no request for an alternative controller or power recline or power tilt feature which is required for the Group 3 PMD to meet coverage criteria. Additionally, the Footplates and calf rests requested were not correctly coded in the request and therefore are non-covered. K0108 cannot be used to code for new items when there are specific HCPCS codes for them. The Calf Rests (E0995) were coded as replacement items on a new issue PMD and therefore cannot be covered.Therefore, we decided that the Plan does not have to pre-approve a group 3 power mobility device with a single power option (K0857) and accessories (E2300, E2361, E1028, E2310, K0108, E0995).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 11, 2019. You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed code cannot be verified. The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible charge for the services you received on July 7, 2015. You asked the Plan to waive the deductible. The Plan denied your request. The Plan says you are responsible for the deductible. 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 $975 deductible that you must pay out-of-pocket before the plan will pay its share for covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $975 deductible that you must pay out-of-pocket before the plan will pay its share for covered medical services. This cost sharing is a contractual obligation that had not been met at the time the services was received on July 7, 2015. Therefore, we decided that the Plan does not have to waive the deductible charge for the services you received on July 7, 2015.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seating system with combination tilt and recline and mechanical shear reduction (E1007) and an elevating leg rest platform (E1012). You asked the Plan to pre-approve the power seating system and elevating leg rest. You say that you would like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says these features are not medically necessary. 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 power seating system and elevating leg rest. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that you are at high risk for development of a pressure ulcer due to mechanical shear, that you use intermittent catheterization for bladder management and does not need a power seating system to manage increased tone or spasticity. Per the Durable Medical Equipment evaluation you do not require mechanical shear reduction in conjunction with tilt and recline or power elevating leg rests to manage your leg edema. 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 power seating system and elevating leg rest have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seating system with combination tilt and recline and mechanical shear reduction (E1007) and an elevating leg rest platform (E1012).
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 for the enrollee. You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 is generally medically stable and the documentation does not support that he has complex medical issues that require acute rehab nursing care or monitoring by an inpatient PMR physician three times per week. The documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Medicare coverage criteria are not met. 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 for the enrollee
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the services you received on January 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that there is a coding
error.
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.
You were provided the services by a contract provider. The file does not show that the Plan provided notice
that the services would not be covered. Under Medicare rules, this means the services is considered approved
by the Plan. Therefore, we decided that the Plan has to pay for the services you received on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for a dental prophylaxis (D1110) provided January 17, 2019.
You asked the Plan to pay for the dental prophylaxis. You say that the cleaning should be covered. The Plan
denied your request. The Plan says that the service is denied.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The record shows the QIC made three attempts to obtain the Evidence of
Coverage and Case File from the health plan. No documentation to support the plan's denial was received.
Therefore, we decided that the Plan has to pay for a dental prophylaxis (D1110) provided January 17, 2019.
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: Favorable

We decided that the Plan has to pay forthe genetic testing rendered on October 6, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says that the services are not covered.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided any clear denial reason or documentation to support that the services are not covered by Medicare.Therefore, we decided that the Plan has to pay forthe genetic testing rendered on October 6, 2018.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve 10 diabetic test strips per day (A4253).
You asked the Plan to pre-approve 10 diabetic test strips per day. You say that the requested items are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the quantity of test strips (code A4253) and lancets (code A4259) that are covered depends on the usual medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin, regardless of their diagnostic classification as having Type 1 or Type 2 diabetes mellitus. 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 10 diabetic test strips per day.
Our reviewer says that the items are medically necessary. Our physician reviewer found the enrollee is clearly checking very often. The download shows an average 9.4x/day for the 2 weeks in June-July. The enrollee was admitted for diabetic ketoacidosis (DKA) and needs to be provided with enough strips to regulate her blood glucose levels well with the pump. The documentation clearly states that she needs to check more often than 2 or even 4 x/day and there is a justified medical need. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 diabetic test strips per day have been met. Therefore, we decided that the Plan has to pre-approve 10 diabetic test strips per day (A4253).
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: Surgery
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for the cataract surgery. We decided that the Plan does not have to waive the deductible and the copayment for the cataract surgery.
You asked the Plan to waive the cost share for the cataract surgery. You say that you feel the anesthesia should be included with the surgery and that you should not be charged extra. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to reduce the cost for the cataract surgery.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that the Plan charged you the out-of-network 45% coinsurance for the cataract surgery, after your deductible was applied. The record shows you received the surgery at an in-network ambulatory surgical center.
The Plan says that you must pay a coinsurance amount of $383 for the cataract surgery. Based on the plan contract, however, you cannot be asked to pay more than a $250 copayment for the cataract surgery. Therefore, we decided that the Plan has to reduce the cost for service from $383 coinsurance to a $250 copayment.
We also decided that the Plan does not have to waive the deductible and copayment for the cataract surgery.
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 $1,000 deductible that applies towards the cataract surgery. Your contract with the Plan clearly says that you must pay a $250 for each Medicare-covered surgery at an in-network ambulatory surgical center. Therefore, we decided that the Plan does not have to waive the deductible for the cataract surgery. See chart below.
Date of Service
Service
Allowed Amount
Deductible/Copayment
Member Liability
February 18, 2020
Cataract surgery
$986.95
$1,000
$135.83
$851.12 (This is the remaining allowed amount $986.95 - $135.83)
$250
$250
Total
$385.83
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from February 13,
2020 through February 19, 2020 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were not supposed to
be in the hospital for that long. The Plan denied your request. The Plan says the claim was processed
accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you were admitted on February 13, 2020 and discharged on February 19, 2020 to
an in-network provider. You were asked to pay a $365 copayment per day from February 13, 2020 through
February 17, 2020, days 1-5 of your inpatient stay. There were no copayment charges from February 18, 2020,
day 6 of your inpatient hospital care until your day of discharge February 19, 2020. Per your contract there is a
$365 copayment per day required for days 1-5 for in-network inpatient hospital care. 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 inpatient hospital care from February 13, 2020 through February 19, 2020 provided
by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on October 7, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 definitive drug testing rendered on October 7,
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 10, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on September 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient
(D0150) provided on March 5, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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.
You exhausted your benefit frequency limit, because you had this same service done on January 16, 2019.
Your EOC states, comprehensive oral evaluation - new or established patient (D0150) - one (1) procedure
every three (3) plan years. Therefore, we decided that the Plan does not have to pay for comprehensive oral
evaluation - new or established patient (D0150) provided on March 5, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Critical Care services (99291) provided December 22, 2019.
You asked the Plan to pay for the critical care services. You say that the services were medically necessary and
the claims were submitted correctly. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 99291 is not supported in the medical record. Specifically, the claim form submitted
lists the rendering provider as the same rendering provider for the same services already performed on the date
of service at issue. Based on this information, we decided that Medicare rules for coverage of the critical care
services have not been met. Therefore, we decided that the Plan does not have to pay for Critical Care services
(99291) provided December 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that it is felt that this level of care is medically needed.
The Plan denied your request. The Plan says IRF criteria are not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 is a 77-year-old man with a history of CHF, hypertension, diabetes,
chronic kidney disease, DVT, and tremor, who was admitted to the hospital on 7/23/20 with weakness and an
episode of hypoglycemia with altered mental status.
The enrollee is generally medically stable and the documentation does not support that he has complex medical
issues that require acute rehab nursing care, or monitoring by an inpatient PMR physician three times per week.
While the enrollee may benefit from continuing PT and OT, the documentation does not support that there is
need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an
interdisciplinary approach to rehabilitation care. It is not clear that the enrollee will be able to fully participate
in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.