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

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee's needs cannot be met at a lower level of care due to significant risk for complications.The Plan denied your request. The Plan says the enrollee does not require frequent rehab physician management, or an interdisciplinary approach for rehab 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 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 physician reviewer found that the enrollee was admitted to the acute hospital for sepsis and an infection of the hip joint. The enrollee's medical conditions are stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. 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 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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Medicare benefit requires the enrollee to have MSI-H or dMMR that has failed prior treatment or is to be combined with chemotherapy for tumors that express PD-L1. The provided records state that the above did not describe the enrollee's current clinical situation. There was no explanation as to why other approved therapies for her clinical condition would not be appropriate. Therefore, this request for Keytruda will be considered not medically necessary at this time based on the provided documentation. Current research does not effectively support the use of Keytruda for the enrollee's specific condition and the documentation does not support that it would be safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the office visit provided on July 7, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that the doctor should have been billed 
as a primary care physician. You say that you shouldn't have been charged a copayment. The Plan denied your 
request. The Plan says that the copayment 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 clearly says that enrollees must pay a $0 copayment for each Medicare-covered primary 
care doctor visit.  
 
The Plan says you must pay a $35 copayment for a specialist visit. Based on the Plan contract, however, you 
cannot be asked to pay more than a $0 copayment for the office visit. This provider is not listed as a specialist. 
This provider is an internal medicine provider, which is considered a primary care physician. Therefore, we 
decided that the Plan has to waive the copayment for the office visit provided on July 7, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from 
March 25, 2020, to June 23, 2020. 
 
You asked the Plan to pay for CPT code S9328. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 looked at the file and Medicare rules. In this case, CPT code S9328 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have 
to pay for the home infusion therapy services (S9328) provided from March 25, 2020, to June 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluoroscopy (77002).
You asked the Plan to pre-approve fluoroscopy. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 fluoroscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found certainly lumbar spine fluoroscopy is very reasonable and necessary for spinal stimulator placement and if the procedure were to be requested and approved the fluoroscopic study would obviously be approved automatically, but without the plan and approval for the placement the request for fluoroscopy is not 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 fluoroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve fluoroscopy (77002).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a subcutaneous cardiac rhythm monitor.
You asked the Plan to pre-approve the insertion of a subcutaneous cardiac rhythm monitor. You say that the records provided support the need for the requested service. The Plan denied your request. The Plan says the enrollee is asymptomatic and has not had a pre-implantable monitor such as Holter.
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 insertion of a subcutaneous cardiac rhythm monitor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had transient asymptomatic heart block effectively treated by discontinuation of b-blocker medication. In this circumstance, if further evaluation for recurrent heart block were thought to be medically necessary then Holter monitoring or off-line event monitoring would be the most appropriate initial tests. There is no evidence the enrollee has had these tests or could not tolerate external monitoring. The documentation does not support the medical necessity for an implantable loop recorder at this time. Coverage criteria are not met since the test in appeal exceeds the enrollee's medical needs at this time. 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 insertion of a subcutaneous cardiac rhythm monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a subcutaneous cardiac rhythm monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 16, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the services were substantiated by the highest 
standards of medical care. The Plan denied your request. The Plan says an authorization was not requested 
prior to offering the services. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on June 16, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Skilled Nursing Facility (SNF) stay 
provided from April 1, 2020 to April 30, 2020. 
 
You asked the Plan to waive the copayment for SNF stay. You say that the enrollee was supposed to be 
discharged after 20 days, but the facility made her stay longer due to COVID-19. The Plan denied your request. 
The Plan says the copayment amount the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay $0 copayment per day for days 1 to 20 and $178 copayment per day for days 21 to 100 for Skilled 
Nursing Facility (SNF) Care. There were 6 days applied to this SNF stay for the March 2020 portion of the 
stay. This portion of the stay lasted 29 days, which were days 7 to 35 of the SNF stay, resulting in a copayment 
obligation of $2,670. 
 
The enrollee has been asked to pay $0 copayment per day for days 1 to 20 and $178 copayment per day for 
days 21 to 100 for SNF stay. SNF stay falls within the Skilled Nursing Facility (SNF) Care benefit category. 
This means that the enrollee has been asked to pay the correct amount based on your contract with the Plan.  
 
This cost sharing is a contractual obligation the enrollee agreed to pay when she enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a Skilled Nursing Facility (SNF) 
stay provided from April 1, 2020 to April 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test with CPT code 87633 provided on July 7, 2020 and July 24, 2020.
You asked the Plan to pay for CPT code 87633. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. CPT code 87633 has a status code of "X" under the MPFSDB and represents a service that is not in the statutory definition of "physician services" for fee schedule payment purposes. Based on this information, we decided that Medicare rules for coverage of CPT code 87633 have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test with CPT code 87633 provided on July 7, 2020 and July 24, 2020.
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 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 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 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on June 23, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the physician services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request 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 Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the physician services provided on June 23, 2020 by an out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the physical therapy services provided by 
an out-of-network provider on September 14, 2020. 
 
You asked the Plan to waive the coinsurance for the physical therapy services. You say that you feel you 
should not be responsible for this cost share amount and you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says you received physical therapy provided by an out-of-network 
provider on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per 
your contract with the Plan. 
 
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 50% of 
the total allowed amount for each Medicare-covered physical therapy visit provided by an out-of-network 
provider. 
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received physical therapy 
services provided by an out-of-network provider on September 14, 2020. You have been asked to pay 50% of 
the total allowed amount for the physical therapy services, totaling $45.15. The physical therapy services fall 
within the Outpatient rehabilitation services benefit category.  
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the physical therapy services provided by an out-of-
network provider on September 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the neurostimulator implantation provided 
on July 15, 2020. 
 
You asked the Plan to waive the copayment for the neurostimulator implantation. You say that you already 
paid $95.32 and are now getting billed for $200. The Plan denied your request. The Plan says the copayment 
applied 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 $200 
copayment for each visit to an ambulatory surgical center. 
 
You have been asked to pay a $200 copayment for the neurostimulator implantation. The neurostimulator 
implantation falls within the "Outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers" benefit category. The records show that the $95.32 was for physician services 
and the $200 copayment is for the facility services. 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 neurostimulator implantation provided on July 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 22, 2017 to August 29, 2017.
You asked the Plan to pay for the SNF care. You say that the SNF care is medically necessary. 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 above 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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 22, 2017 to August 29, 2017.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on May 18, 2020 
and billed under code 77062. 
 
You asked the Plan to pay for code 77062. You say that this claim should be paid. The Plan denied your 
request. The Plan says code 77062 has a status code indicator of "I" and is not paid on Medicare claims. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case code 77062 is not a code payable on 
Medicare claims. Medicare uses another code for reporting these services. Therefore, we decided that the Plan 
does not have to pay for imaging services provided to the enrollee on May 18, 2020 and billed under code 
77062.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services rendered on July 11, 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99285 was not billed with an 
appropriate primary diagnosis code. 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 emergency 
room services rendered on July 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no failed four week trial of a E0650 or E0651 pump. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided, there is no documentation that the enrollee has unique 
characteristics that would indicate the segmental pump over a standard pump. There is no documentation of a 
trial and failure of the standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a segmented pneumatic compression device for the enrollee.