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

 We decided that the Plan does not have to waive the copayments and coinsurance for a positron emission tomography (PET) scan of the heart with rubidium injection, cardiovascular stress test, and regadenoson injection provided on September 28, 2021.  You asked the Plan to waive the copayments and coinsurance for the PET scan, stress test, and injection. You say that all of the supplies were necessary for the PET scan and you thought you would only have a $110 copayment. The Plan denied your request. The Plan says the correct copayments and coinsurance were 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 $110 copayment for radiological diagnostic services, not including X-rays.  Your contract with the Plan also clearly says that you must pay a 20% coinsurance for medical supplies, such as chemical agents used in certain diagnostic tests.  Your contract with the Plan also clearly says that you must pay a $20 copayment for non-radiological diagnostic services, including stress tests.  Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Part B drug, including injectable drugs.  Procedure/Drug Allowed Amount Copayment/20% Coinsurance PET scan $1,542.28 $110.00 (Copayment) Rubidium Injection $1,041.50 $208.30 (Coinsurance) Cardio Stress Test $69.96 $20.00 (Copayment) Regadenoson Injection $237.24 $47.45 (Coinsurance) Total:  $385.75  You have been asked to pay $385.75 for the PET scan, stress test, and injection. The PET scan with rubidium injection and the stress test fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The regadenoson injection falls within the Medicare Part B Prescription 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 copayments and coinsurance for a positron emission tomography (PET) scan of the heart with rubidium injection, cardiovascular stress test, and regadenoson injection provided on September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical pathology services provided on October 7, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the surgical pathology services. You say that the enrollee does not come to the lab which means they are not using their out-of-network benefits. You say the participating doctors sends the specimen. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the referring provider was also out-of-network. Therefore, we decided that the Plan does not have to pay for surgical pathology services provided on October 7, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for surgical services provided on August 26, 2020.  You asked the Plan to waive the copayment for the surgical services. You say that you paid the copayments and would like the bills reviewed. 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 $250 copayment for surgery services provided at an outpatient hospital.   You have been asked to pay a $250 copayment for the surgical services. The surgical services fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 surgical services provided on August 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for office services provided on August 31, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office services. You say that services were provided to the enrollee out of medical necessity. The Plan denied your request. The Plan says the provider is an out-of-network provide and there was no referral from a network provider for 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 had network providers available who could have provided 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 office services provided on August 31, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a neck MRI (72141) provided on September 3, 2021.  You asked the Plan to waive the copayment for the neck MRI. You say that the services should be covered as you were not informed of the copayment beforehand. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $225 copayment for Outpatient diagnostic tests and therapeutic services and supplies.      You have been asked to pay a $216.67 copayment for a neck MRI, which is less than the $225 stated in the Plans contract. MRIs fall 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. 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 a neck MRI (72141) provided on September 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an impacted tooth removal (D7240), and nitrous oxide inhalation (D9230) provided by an out-of-network provider on July 23, 2021.  You asked the Plan to pay for a comprehensive oral evaluation, an impacted tooth removal, and nitrous oxide inhalation. You say that you were told that you could go to any in-network or out-of-network provider. The Plan denied your request. The Plan says the dental services that were provided are not covered dental 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 pay for a comprehensive oral evaluation (D0150), an impacted tooth removal (D7240), and nitrous oxide inhalation (D9230) provided by an out-of-network provider on July 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home ventilator.  You asked the Plan to pre-approve a ventilator. You say that BiPAP is insufficient due to severity of condition. The Plan denied your request. The Plan says a ventilator in a setting that could be delivered by BiPAP is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 a ventilator. Our physician reviewer found that the enrollee has obstructive sleep apnea and obesity-hypoventilation syndrome. There is no diagnosis of COPD, thoracic restrictive disease, or neuromuscular disease. She does not have a diagnosis for which Medicare covers a home ventilator. Therefore, a home ventilator 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 a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not 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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tachycardia site mapping (93609) and comprehensive electrophysiologic evaluation (93653) provided on September 15, 2021.  You asked the Plan to pay for the tachycardia site mapping (93609) and comprehensive electrophysiologic evaluation (93653). You say that the documentation shows logical progression of services leading up to the services provided on September 15, 2021. You say that the claim should be reviewed and reimbursed. The Plan denied your request. The Plan says that CPT codes 93613 and 93280 were overturned. The Plan also says an appropriate modifier was not billed with CPT code 93653 and there is no modifier allowed to bypass the edit for CPT code 93609.  The Plan must follow Medicare rules. In this case, we have confirmed that code 93609 is a column II code to column I code 93613. This claim cannot be billed with a modifier to bypass the edit. CPT code 33208 has a global period of 90 days. CPT code 93653 was billed within 90 days by the same provider. There is no indication that this service is unrelated. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the tachycardia site mapping (93609) and comprehensive electrophysiologic evaluation (93653) provided on September 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Vancomycin.  You asked the Plan to pre-approve Vancomycin. You say that the medication is needed for the enrollee to get better. The Plan denied your request. The Plan says Vancomycin to be administered at home is not covered under the 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 Vancomycin.    Benefits for Vancomycin 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 acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. The Plan denied your request. The Plan says IRF care is not considered medically reasonable and necessary in this case. The Plan says that the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative 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 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a seizure. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on August 19, 2021, by an OON provider.  You asked the Plan to pay for an office visit. You say that the enrollee was seen, and the claim should be paid. The Plan denied your request. The Plan says the provider is a non-participating provider with no prior authorization. Also, there was no referring in-network provider and the services provided were not urgent or emergent.  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 had network providers available who could have provided 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 an office visit provided on August 19, 2021, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Retacrit.  You asked the Plan to pre-approve Retacrit. You say that this is medically necessary. The Plan denied your request. The Plan says this use is not supported.  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 Retacrit. Our reviewer says that there is no documentation that Retacrit is medically reasonable and necessary for the patient as defined by Medicare criteria. Our physician reviewer found the submitted records do not document the patient currently has a hemoglobin level less than 10 grams per decilitre or a hematocrit level less than 30%.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hip replacement surgery.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is no documentation of how daily activities are affected.  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 requested services. Our physician reviewer found that the enrollee is being treated for right hip degenerative joint disease and unilateral primary osteoarthritis of the right hip. He presented with right hip pain that has been getting worse over the past month. He is weightbearing. Detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. There is only documentation of medications having been trialed. Additionally, he is noted to be a current everyday smoker. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for right hip replacement surgery is not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve hip replacement surgery.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve the application of Theraskin (15275, Q4121)  You asked the Plan to pre-approve the application of Theraskin. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says that the member does not meet Plan criteria for coverage of the requested service.  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 application of Theraskin. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the record supports that the member had a large skin defect after Mohs surgery.  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 application of Theraskin have been met. Therefore, we decided that the Plan has to pre-approve the application of Theraskin (15275, Q4121)   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: Hospice
Decision: Favorable

 We decided that the Plan has to pay for home care services provided from August 1, 2020, through  August 31, 2020.  You asked the Plan to pay for home care services. You say that the Plan's call center representative gave you misleading or incorrect information. The Plan denied your request. The Plan says that the service was billed without a revenue code or a CPT code.  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. Specifically, the Plan has not provided us with proof of Hospice enrollment. The Plan has not supported the denial by providing us with the correct revenue code and/or CPT code. Therefore, we decided that the Plan has to pay for home care services provided from August 1, 2020, through  August 31, 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.