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 inpatient rehabilitation is medically necessary for the enrollee to regain maximum function. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The necessary services can be provided in a lower level of 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 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 rehabilitation care. 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 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: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided September 21, 2021, by an out-of-network provider with 50% coinsurance up to the $500 maximum benefit.  You asked the Plan to pay for the dental cleaning and periodic oral exam. You say that you would like the services covered. The Plan denied your request. The Plan says that these services are not covered because the provider does not participate in Medicare.  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 the dental cleaning and periodic oral exam once every six months with 50% coinsurance when provided OON. There is a maximum plan benefit coverage amount of $500 per year.  We looked at the file and Medicare rules. In this case the Plan denied coverage on the basis that the provider has opted out of Medicare. We checked the Medicare Provider Opt-Out Database and the provider at issue does not appear to be on the list. Based on this information, we decided that the Plan's rules for coverage of the dental cleaning and periodic oral exam have been met. Therefore, we decided that the Plan has to pay for the prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided September 21, 2021, by an out-of-network provider with 50% coinsurance up to the $500 maximum benefit.   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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  

You asked the Plan to pre-approve the SNF admission. You say that it is felt that SNF care is needed. The Plan denied your request. The Plan says the enrollee's needs are being met in the current facility.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on 12/30/2021 with a pontine hemorrhagic stroke and was found to be COVID positive on 1/24/2022. The enrollee has been in an acute rehabilitation facility since 1/25/2022.   

The enrollee does not have documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  The enrollee is likely approaching a plateau in function.  Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or established patient (D0180), bitewings - four radiographic images (D0274), and panoramic radiographic image (D0330) provided September 14, 2021.

You asked the Plan to pay for the comprehensive periodontal exam, bitewing x-rays and panoramic x-rays. You say that you have used this dental office for years and the dentist said they haven't had issues with claims until recently. The Plan denied your request. The Plan says these services are not covered when the services are rendered by a provider who has opted out of Medicare.

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 the comprehensive periodontal exam, bitewing x-rays and panoramic x-rays when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. 

We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the comprehensive periodontal exam, bitewing x-rays and panoramic x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or established patient (D0180), bitewings - four radiographic images (D0274), and panoramic radiographic image (D0330) provided September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ophthalmology examination you had on October 8, 2021.

You asked the Plan to reduce the copayment for the ophthalmology exam. You say that this should have been an annual eye exam that just has a $15 copayment. The Plan denied your request. The Plan says you were charged this copayment correctly because you were evaluated or treated for a medical condition during this visit.

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 visits for services to diagnose or treat diseases or conditions of the eye. The contract also says that you pay $15 for one annual routine eye exam. However, if you receive services that address a medical condition during the same office visit, you pay a $40 copayment. 

You have been asked to pay a $40 copayment for the ophthalmology exam. We looked at the medical records from this visit to determine if you received services beyond an annual routine eye exam. According to the medical records, you were also evaluated for cataracts, chronic posterior vitreous detachment, and blepharitis. These are medical conditions beyond the scope of a routine eye exam. 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 reduce the copayment for the ophthalmology examination you had on October 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the interpretation of the Fluorodeoxyglucose positron emission tomography (FDG PET) imaging provided on July 19, 2021.  

You asked the Plan to pay for the FDG PET scan interpretation. You say that the required modifier was used so this claim should be paid. The Plan denied your request. The Plan says the required modifier was not reported on this claim.  The Plan must follow Medicare rules. 

Medicare rules say that for billing FDG PET scans for oncologic conditions, providers must use either modifier -PI or -PS to identify whether the scan was done for initial treatment planning, or subsequent treatment planning.  

In this case, neither of these modifiers was used. As such, we find that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the Fluorodeoxyglucose positron emission tomography (FDG PET) imaging provided on July 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluoxetine for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Fluoxetine for the enrollee.
Benefits for this drug 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 you need IRF care to regain mobility and return home safely. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The services you need can be provided in a lower level of 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 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. 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: Imaging
Decision: Favorable

We decided that the Plan has to pay for the magnetic resonance angiography (MRA) (70544) provided on June
8, 2021.
You asked the Plan to pay for the MRA. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says that an edit exists between 70544 and 70551.
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 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 MRA. Our reviewer says that CPT code 70544 meets
criteria for billing and reimbursement consideration. Our reviewer found an MRA takes more detailed images
of the blood vessels than the organs or tissue surrounding them like an MRI. Procedure report documents
specific areas images were taken, to support reporting the magnetic resonance imaging (MRI) procedure with
MRA procedure, and therefore should be covered.
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 MRA have been met. Therefore, we decided that the Plan has to pay for the
magnetic resonance angiography (MRA) (70544) provided on June 8, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from October 4, 2017, through October 5, 2017, billed with secondary diagnosis code E87.1.

You asked the Plan to pay for the inpatient care as billed. You say that this claim was billed correctly. The Plan denied your request. The Plan says the secondary diagnosis is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with secondary diagnosis code E87.1, defined as hypo-osmolality and hyponatremia. 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 inpatient care as billed. Our reviewer says that the reported diagnosis E87.1 is not supported by the records. Our physician reviewer found the enrollee was a then, 82-year-old female who presented to the facility following a fall. She presented to the emergency room (ER) with pain and swelling to the left ankle following a fall. An x-ray was obtained, and the patient was diagnosed with an ankle fracture that was successfully reduced in the ER.

The patient was subsequently admitted and underwent an open reduction and internal fixation of the trimalleolar ankle fracture. The clinical evidence did not support assignment of code E87.1. In this case, the lowest sodium level was 131, and there was no follow-up value found for review. Therefore, there was insufficient objective clinical evidence to validate the diagnosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from October 4, 2017, through October 5, 2017, billed with secondary diagnosis code E87.1.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oximeter for the enrollee.
You asked the Plan to pre-approve an oximeter. You say that an oximeter is medically necessary. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan must follow Medicare rules. Medicare does not cover self-help or precautionary devices. Medicare specifically states oximeters are not covered. While this item may be beneficial for the enrollees use, it is not covered by the Plan or by Medicare. Therefore, we decided that the Plan does not have to pre-approve an oximeter for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient cataract surgery you had on June 24, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you already paid the provider and the procedure was not successful. 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 $350 copayment for outpatient surgery.
You have been asked to pay a $350 copayment for the outpatient surgery. 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. It appears that because you received toric intraocular lens during this procedure, that may have been what you paid for up front with the provider. Medicare generally only pays up to the cost of a conventional lens. The difference in cost between the toric lens you received and a conventional lens is likely what you have paid to this provider. This is separate and distinct from the copayment for the surgery itself. If you have questions regarding the toric lens you received, please contact the provider directly. Therefore, we decided that the Plan does not have to waive the copayment for outpatient cataract surgery you had on June 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablets for the enrollee.
You asked the Plan to pre-approve Eliquis tablets. You say that Eliquis tablets are medically necessary. The Plan denied your request. The Plan says Eliquis tablets are not covered under Medicare Part B.
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 Eliquis tablets for the enrollee.
Benefits for Eliquis tablets 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo combined with Yervoy.

You asked the Plan to pre-approve Opdivo combined with Yervoy. You say that the requested Opdivo combined with Yervoy is medically necessary. The Plan denied your request. The Plan says the requested Opdivo combined with Yervoy is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Opdivo combined with Yervoy. Our reviewer says that the requested Opdivo combined with Yervoy is not medically necessary. Our physician reviewer found the requested use of Opdivo combined with Yervoy is not FDA-approved for the enrollee's diagnosis. The combination is approved for 1st line treatment, and this would be 2nd line. The use of Opdivo combined with Yervoy is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo combined with Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo combined with Yervoy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist office visits rendered from January 7, 2020, to August 17, 2020.
You asked the Plan to waive the copayment for specialist office visits. You say that your reason for not affording these charges is that your income now is $1,500 monthly only. The Plan partially denied your request. The Plan says you were charged the correct cost sharing amount for some of the dates of service. The Plan also says you were incorrectly charged for the following dates of service: January 9, 2020; January 13, 2020; January 30, 2020; March 5, 2020; March 16, 2020; April 22, 2020; June 1, 2020; July 9, 2020; and August 17, 2020. The Plan also says that they have reduced the copayments applied to those dates of service.
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 $45 copayment for physician specialist services. You have been asked to pay a total of a $675 copayment for 15 specialist office visits provided from January 7, 2020, to August 17, 2020 ($45 copayment x 15 specialist office visits = $675). Specialist office visits fall within the physician/practitioner services including doctor's office visits benefit category. The record shows that the Plan reduced the copayment from $50 to $45 for the following dates of service: January 9, 2020; January 13, 2020; January 30, 2020; March 5, 2020; March 16, 2020; April 22, 2020; June 1, 2020; July 9, 2020; and August 17, 2020. The record shows the Plan applied the correct copayment for the remaining dates of service. 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 specialist office visits rendered from January 7, 2020, to August 17, 2020.
Your complaint about the service potentially applied to the wrong eye is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.