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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for IRF care 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but you do not require this on an intensive rehabilitation facility therapy program level 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 16, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says CPT 88364 is an add-on code without a primary procedure, and CPT 85060 was billed with an inappropriate place of service for physician interpretation.
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 the denied codes is: CPT 85060: Blood smear, peripheral, interpretation by physician with written report CPT 88364: In situ hybridization (eg, FISH), per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure) 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 services. Our reviewer says that the services at issue in this case were not coded or billed correctly. Our physician reviewer found since CPT 85060 was reported as an outpatient laboratory service (place of service 22) and not inpatient place of service (21) it is not payable. Medicare will only pay for 85060 for hospital inpatients. The denial for CPT code 88364 is related to the fact that it is an add-on code and can only be reported with an approved primary procedure code which CMS has specified. In this case, the primary procedure code was reported but not in an approved manner. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on September 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Radiation Therapy services provided July 30 to September 13, 2019.
You asked the Plan to waive the copayment for the radiation therapy services. You say that the copayment should be waived. 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 $30 copayment for Therapeutic Radiology Services. You have been asked to pay a $30 copayment for the radiation therapy services. The radiation therapy services fall within the Therapeutic Radiology 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 Radiation Therapy services provided July 30 to September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy infusion (96413, 96417 and 96415) provided on August 7, 2019.
You asked the Plan to pay for the chemotherapy infusion. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the time over which the infusion was administered is not documented.
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 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. The CPT Manual definition of code 96417 is chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure). The CPT Manual definition of code 96415 is chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure). We asked our coder 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 chemotherapy infusion. Our reviewer says that CPT codes 96413, 96417 and 96415 do not meed criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not indicate the start and stop times or total time during which the chemotherapy administration was rendered. 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 chemotherapy infusion have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy infusion (96413, 96417 and 96415) provided on August 7, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 PT visits (G0151).
You asked the Plan to pre-approve the additional PT. You say that the plan has been to continue on a maintenance program with the member to maintain his progress and not to allow the mobility and functional gains to regress. The Plan denied your request. The Plan says there has been adequate time to instruct and transition to a home program to maintain strength and mobility. The clinical documentation does not support medical complications that require unique the skills of a physical therapist.
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 additional PT. Our reviewer says that based on available records, the member does not meet criteria for coverage of the requested home health PT visits. Our physician reviewer found the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services which are medically necessary for the member. The enrollee has made significant progress with therapy and can be transitioned to a home 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 additional PT have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 PT visits (G0151).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on September 7, 2019.
You asked the Plan to pay for these drugs. You say that you did not self-administer any drugs. The Plan denied your request. The Plan says that this is not covered by the Plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on September 7, 2019.
Benefits for these drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz Fx for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary osteoarthritis of the right knee. He has not tried and failed the plan's required drugs of orthovisc and monovisc. The records do not show that the required drugs would be less effective or contraindicated; therefore, Supartz Fx is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz Fx for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

Medicare rules say that the Plan must give the member a subscriber agreement. It is a contract between the Plan and the member. It is usually called the "Evidence of Coverage" (EOC) or "Member Agreement." We read this contract carefully to see what the Plan is supposed to cover.MedicarerulesThe rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says if a resin-based composite or glass ionomer restoration is placed in a posterior tooth (except those placed in the buccal (facial) surface of bicuspids), it will be considered an elective procedure and an amalgam allowance will be provided and you will pay the difference in the cost. The Plan contract also says after the $100 deductible is met, you pay 20% coinsurance up to the $1,500 annual dental benefit maximum. You can find this information on pages 83 and 84 of the Plan's 2019 Evidence of Coverage.Explanation of decisionWe decided that the Plan does not have to pay the full amount forthe resin based composite, 1 surface, posterior, (D2391) provided on October 1, 2019.You asked the Plan to pay the full amount forthe dental services. You say that you did not request a resin based composite. You say that you expected that the dental services performed would conform to the dental insurance requirements as the previous performed procedures had.The Plan denied your request. The Plan says posterior composite fillings are paid at the amalgam rate. The Plan says that the balance up to the dentist's maximum allowable fee for the composite restoration is your responsibility.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 restorations are a covered service, a resin based composite restoration in a posterior tooth will be paid at the rate of an amalgam and you will pay the difference in the cost. The record shows that the Plan paid 80% of the allowed amount at the rate of $93.60. You are responsible for the 20% coinsurance. Therefore, we decided that the Plan does not have to pay the full amount for the resin based composite, 1 surface, posterior, (D2391) provided on October 1, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was observed in the hospital on 1/31/2020 for dyspnea. The enrollee was found to have low potassium. She was given IV Lasix for leg swelling from congestive heart failure. She currently receives home health care services 4 to 6 hours per day. Her activity is limited by lower extremity edema and dyspnea, but she is able to transfer and use the toilet with supervision. She requires minimal assistance with grooming and bathing. She is ambulating with minimal/contact guard assist with rolling walker. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee does not require this on an intensive rehabilitation facility therapy program level 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on September 12, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on September 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear provided on July 18, 2019.
You asked the Plan to pay for the eyewear. You say that you were not aware when your previous vision service was. The Plan denied your request. The Plan says you received routine vision services on October 23, 2017 and it has not been two years since.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine vision services every two years. This benefit is administered on a rolling calendar year since your last date of service. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear provided on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 12, 2019 by an out of network provider.
You asked the Plan to pay for the injection (96372). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says prior authorization was not obtained as required under the Plan's benefits.
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 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 the medical services provided on September 12, 2019 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH), having been admitted with a severe chronic obstructive pulmonary disease (COPD) exacerbation. The enrollee was intubated/ventilated upon admission and subsequently received a tracheotomy. The enrollee appeared to be tolerating ventilator weaning, but has recently developed diarrhea, anemia and hypotension. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on September 17, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that you do not want to pay an additional $23.06 because the lab messed up on what should have been done on the first visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 copayment for laboratory services at an in-network outpatient hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $40 copayment for laboratory work.
You have been asked to pay a $23.06 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The record shows you received additional laboratory services.
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 laboratory work provided on September 17, 2019.