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

We decided that the Plan does not have to pay for laboratory services provided on August 31, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on December 2, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on November 3, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on November 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment and deductible for inpatient hospital care received from March 20, 2016, through March 28, 2016.
You asked the Plan to waive the copayment and deductible for inpatient hospital care. You say that you should not have to pay these charges. The Plan denied your request. The Plan says the copayment and deductible were 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 $320 deductible before the Plan will begin to pay for their share and a $231 copayment for inpatient hospital care.
You have been asked to pay your $320 deductible and a $231 copayment for inpatient hospital care. The
services at issue fall 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 and deductible for inpatient hospital care received from March 20, 2016, through March 28, 2016.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq Tab.
You asked the Plan to pre-approve Myrbetriq Tab. You say that you recommend this drug to treat the enrollee's medical condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.
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 pre-approve Myrbetriq Tab.
Benefits for Myrbetriq Tab 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: 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 LTACH services are medically necessary in this case. The Plan denied your request. The Plan says the clinical assessment does not support the expectation of a stay of at least 25 days. Criteria for an LTACH have not been met, and the enrollee's medical needs are being met in the current acute setting. An LTACH would provide no clinical advantage.
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 appears to be gradually improving and requires additional short-term acute care services which can safely be performed at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current acute care hospital. Therefore, this request for LTACH services will be considered not medically necessary, as there is no notable advantage to a transfer at this time. Transfer to another level of care may be considered once treatment is completed.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (01936-QS) provided on November 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed without an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that The QS modifier can be used by a physician or a qualified nonphysician anesthetist and is for informational purposes. Providers must report actual anesthesia time and one of the payment modifiers on the claim.
We looked at the file and Medicare rules. The anesthesia services in this case were billed with modifier QS, however, the services were not billed with an appropriate payment modifier. 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 the anesthesia services (01936-QS) provided on November 30, 2020
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve bioimpedance spectroscopy services.

You asked the Plan to pre-approve the requested services. You say that the requested service can detect changes in extracellular fluid. The Plan denied your request. The Plan says that the medical literature does not support this measurement.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 requested services. Our physician reviewer found that the enrollee has breast cancer and lymphedema. The requested use is supported by clinical research that appears in a CMS-approved medical journal. The Annals of Plastic Surgery (58(5):541-543, May 2007) shows the use of bioimpedance analysis to evaluate lymphedema. Therefore, the documentation does support the medical necessity of the requested services. 

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 requested services have been met. Therefore, we decided that the Plan has to pre-approve bioimpedance spectroscopy services.

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 pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.

While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants, and custom abutments and abutment supported cast metal crowns.
You asked the Plan to pre-approve dental implants, and custom abutments and abutment supported cast metal crowns. You say that you are in pain and have headaches. The Plan denied your request. The Plan says the records show the enrollee is missing more than one tooth in the arch for which implants are being requested. The Plan says that there are other treatment options to replace the enrollee's missing teeth, such as a a partial denture. The Plan says that the custom abutments and abutment supported crowns are not covered because the other services related to these procedures were not approved.
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. The Plan covers dental implants, and custom abutments and abutment supported cast metal crowns when the services are medically necessary and reasonable. 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 dental implants, and custom abutments and abutment supported cast metal crowns. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the dental implants, while being a reasonable restorative plan for the situation, is not then only method for restoring the teeth in question. There would be other options such as fixed bridgework and removable appliances. Therefore, dental implants are not medically necessary but are a reasonable alternative treatment. There are two missing posterior teeth on the upper arch (3 and 14), and two missing teeth on the lower arch (18 and 30). The implants being requested are not being used to support a full denture. There are a significant number of teeth remaining in the arches, along with two restored single implant teeth. The requested implants would complete a 28-tooth occlusion. The custom abutments and supported cast metal crowns are not medically necessary. The proposed treatment is a reasonable alternative treatment for which there are other options as well, including removable appliances. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of dental implants, and custom abutments and abutment supported cast metal crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve dental implants, and custom abutments and abutment supported cast metal crowns.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services (99233) provided to the enrollee from October 29, 2020, to October 31, 2020.

You asked the Plan to pay for the services. You say that these services have been deemed payable. The Plan denied your request. The Plan says the records did not support the provided services.

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 99233 is "Subsequent hospital care, per day, for the evaluation and management of a patient." 

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation did not support the reported level of evaluation and management on October 29, 2020. The documentation supports "Problem Focused history due to only past medical history" was performed, "Expanded Problem Focused exam" was performed with 5 organ systems reviewed, and "Medical Decision Making of High Complexity" was performed. Per the CPT guidelines 2 of 3 key components must be met to report the level of evaluation and management performed. In this case, there is a more appropriate code to report for service performed. For October 30 and 31, 2020, the documentation submitted did not include an evaluation and management service provided for these dates of service, and therefore cannot be confirmed as performed.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient services (99233) provided to the enrollee from October 29, 2020, to October 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit provided by a licensed clinical social
worker (LCSW) on February 10, 2021.
You asked the Plan to pay for office visit. You say that you were never notified of a change in benefits, and
therefore your clients continued to be seen via telehealth. The Plan denied your request. The Plan says this
service is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that Certified Social Workers are not eligible to
enroll in Medicare and are not payable.
We looked at the file and Medicare rules. This provider is not payable by Medicare. Based on this information,
we decided that Medicare rules for coverage of office visit have not been met. Therefore, we decided that the
Plan does not have to pay for a psychotherapy visit provided by a licensed clinical social worker (LCSW) on
February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the vacuum drain bottles, the Part B drugs, and the inpatient hospital admission provided from September 4, 2020, to September 9, 2020.

You asked the Plan to waive the cost share for the vacuum drain bottle, the Part B drugs, and the inpatient hospital admission. You say that the maximum out of pocket amount was met and the enrollee should not be responsible for these costs. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for each in-Network Medicare-covered item, 20% coinsurance for all other in-network drugs covered under Medicare Part B and $325 copayment per day, days 1 to 6 for inpatient hospital care. 

The enrollee has been asked to pay $1,081.44 for the vacuum drain bottle, the Part B drugs, and the inpatient hospital admission. The vacuum drain bottle falls within the "Durable medical equipment (DME) and related supplies" benefit category. The Part B drugs fall within the "Medicare Part B prescription drugs" benefit category. The inpatient hospital admission falls within the "Inpatient hospital care" benefit category.

This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the vacuum drain bottles, the Part B drugs, and the inpatient hospital admission provided from September 4, 2020, to September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit and the ECG to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit and the ECG. You say that your heart is out of rhythm and you need to see an electrophysiologist. The Plan denied your request. The Plan says the provider is out of network
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit and the ECG to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Northera cap 200mg 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 this is a self-administered drug.

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 pre-approve Northera cap 200mg for the enrollee.
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 enrollee needs long-term care. The Plan denied your request. The Plan says the enrollee's care can be provided in the current inpatient hospital.
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 physician reviewer found that the enrollee was admitted to the acute care hospital following a fall which resulted in an acute-on-chronic subdural hemorrhage. A craniotomy with subdural hematoma evacuation was performed. He was minimally following commands. LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that he requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The requested LTACH services are/are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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.