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 you would like the IRF admission covered. The Plan
denied your request. The Plan says you do not meet criteria for IRF admission.
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 that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation
does support a need for physical and/or occupational therapy, there is no documented need for an intensive,
multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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: Favorable

We decided that the Plan has to pay for the comprehensive audiometry threshold evaluation and speech
recognition (92557) provided on January 6, 2021.

You asked the Plan to pay for the comprehensive audiometry threshold evaluation and speech recognition. You
say that this claim should be reprocessed and approved for payment. The Plan denied your request. The Plan
says that this claim has denied correctly for a duplicate claim submitted.

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. In this case, the Plan has not substantiated their denial. The Plan has denied this
as a duplicate appeal that should only be reported one time. However, there is no evidence that this claim was
submitted with more than one unit. Therefore, we decided that the Plan has to pay for the comprehensive
audiometry threshold evaluation and speech recognition (92557) provided on January 6, 2021.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for an intraoral complete series of
radiographic images (D0210) provided on March 15, 2021.

You asked the Plan to pay an additional amount for an intraoral complete series of radiographic images. You
say that you were told the service would be covered. The Plan denied your request. The Plan says the coinsurance
was applied correctly.

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 have been asked to pay $49.80 for an intraoral complete series of radiographic images. The service at
issue falls within the Class 2 Basic Services dental 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 pay an
additional amount for an intraoral complete series of radiographic images (D0210) provided on March 15,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 26, 2021.
You asked the Plan to pay for the lab services. You say that you provided services in good faith. The Plan denied your request. The Plan says if documentation to support medical necessity is not submitted, the claim is denied.
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the beneficiary's medical documentation.
We looked at the file and the rules. We find that the testing at issue is not supported in the medical record. Specifically, there are insufficient medical records to show that the results of testing would be used for a specific diagnosis or treatment strategy. The file shows that the Plan made multiple attempts to obtain further information, with no success. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 26, 2021.
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 notes do not show that the enrollee's care specifically requires the involvement of a doctor in the field of rehabilitation medicine.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's medical problems are stable and there are no complex nursing or rehabilitation needs. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group three power wheelchair with multiple power options and accessories.
You asked the Plan to pre-approve the group three power wheelchair with multiple power options and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says the items 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 group three power wheelchair with multiple power options and accessories. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient does not have pressure wounds to justify power tilt or power recline. The patient does not have spasticity to require suspension, and there was no support for the patient to require other components for mobility. There was insufficient support made for this device or evidence of failure of other means of mobility support.
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 group three power wheelchair with multiple power options and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the group three power wheelchair with multiple power options and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge management (99217)
provided on June 16, 2021.

You asked the Plan to pay for the observation care discharge. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does
not support the service billed.

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 99217 is observation care discharge day management
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital
"observation status" if the discharge is on other than the initial date of "observation status." To report services
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236
as appropriate.])

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 observation care discharge. Our reviewer says that CPT
code 99217 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical
records provided do not include sufficient documentation to validate Observation care discharge day
management. This code is to be utilized to report all services provided to a patient on discharge from outpatient
hospital "observation status" if the discharge is on a date other than the initial date of "observation status." This
service cannot be verified.

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 observation care discharge have not been met. Therefore, we decided that
the Plan does not have to pay for the observation care discharge management (99217) provided on June 16,
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission and services provided from March 20, 2021, to March 24, 2021.
You asked the Plan to waive the copayment for the inpatient admission. You say that you cannot afford the cost. The Plan denied your request. The Plan says the copayment was 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 $370 copayment per day for days 1-5 for inpatient hospital care. You have been asked to pay a total of $1,480 ($370 copayment x 4 days =$1,480) for the inpatient admission.
The inpatient admission falls within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient admission and services provided from March 20, 2021, to March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Golimumab injections you received on May 25, 2021, and June 22, 2021.
You asked the Plan to waive the coinsurance for the Golimumab injections. You say that you were not aware of the cost and you cannot afford this medication. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Golimumab injections. The Golimumab injections fall within the Medicare Part B drugs 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 Golimumab injections you received on May 25, 2021, and June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from May 20, 2021, to May 25, 2021.
You asked the Plan to waive the copayment for the inpatient hospital admission. You say that the bill is expensive and more than you can afford. 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). Your contract with the Plan clearly says that you must pay a $325 copayment per day, days 1-6 for each Medicare-covered hospital stay.
You have been asked to pay a $325 copayment for each day of the inpatient hospital admission. ($325 x 5 days = $1,625). The inpatient hospital admission falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from May 20, 2021, to May 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on January 19, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says based on the enrollee's hospice election at the time of service, this claim should be submitted to Original Medicare first.
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 medical services provided to the enrollee on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenetic testing provided on May 12, 2021.

You asked the Plan to pay for the testing services. You say that the results of the testing allows physicians to make treatment decisions. The Plan denied your request. The Plan says the service was not supported by the procedure code billed.

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 the rules. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenetic testing provided on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9222, D9223 x3).
You asked the Plan to pre-approve deep sedation/general anesthesia. You say that the services at issue are
necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep
sedation/general anesthesia (D9222, D9223 x3).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE)
you had on May 6, 2021.
You asked the Plan to waive the copayment for the TTE. You say that you assumed that all testing was covered
under the office visit copayment. The Plan denied your request. The Plan says you were charged this
copayment 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 $175
copayment for radiological diagnostic services performed in a physician's office.
You have been asked to pay a $175 copayment for the TTE. The TTE falls within the radiological diagnostic
services performed in a physician's office benefit category. The physician office visit copayment does not
include diagnostic testing. This is a separate service and separate cost sharing applies, that is why your
Evidence of Coverage explicitly states that this copayment applies even if you get this service in your
physician's office. 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 transthoracic
echocardiography (TTE) you had on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomic testing provided on June 2, 2021.
You asked the Plan to pay for the testing services. You say that the testing was deemed medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the beneficiary's medical documentation. We looked at the file and the rules. The provided pharmacogenetic testing was reportedly ordered to make decisions about the enrollee's medications. Medications should be provided based on the presence of a diagnosis and should be adjusted based on a response to the medication. In this case, there are insufficient records that clearly document the enrollee's medication responses. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomic testing provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5261), provided on April 8, 2021.
You asked the Plan to pay for the hearing aid. You say that the item is medically necessary. The Plan denied your request. The Plan says this is item must be purchased from a network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only you must use a doctor in the Plan's hearing network. 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 hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5261), provided on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical collar (L0180) and prefabricated hip abduction orthosis (L1686), provided on December 29, 2020.
You asked the Plan to pay for the cervical collar and prefabricated hip abduction orthosis. You say that the items were medically necessary. The Plan denied your request. The Plan says the denied item was ordered on December 16, 2020; however, the only medical records submitted were for the member's January 7, 2020 office visit. There is an eleven month gap in the medical record submitted by the provider.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. No report of cervical or right hip osteoarthritis was documented or the prescribed plan for the cervical collar or prefabricated hip abduction orthosis around the time of this request to help support these devices. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the cervical collar (L0180) and prefabricated hip abduction orthosis (L1686), provided on December 29, 2020.