Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance and copayment for an onabotulinumtoxina
injection (J0585) and an anesthetic agent(s) and/or steroid injection (64405) provided on June 23, 2021.
You asked the Plan to waive the coinsurance and copayment for an onabotulinumtoxina injection (J0585) and
an anesthetic agent(s) and/or steroid injection (64405). You say that the services should be covered as you were
not made aware of the cost-sharing 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 20%
coinsurance for Medicare Part B Prescription Drugs and a $40 copayment for Physician/Practitioner Services,
Including Doctor's Office Visits, specifically services obtained from a specialist in a specialist's office.
You have been asked to pay a 20% coinsurance for an onabotulinumtoxina injection (The allowed amount is
$1,212, 20% of that is $242.40) and a $40 copayment for an anesthetic agent(s) and/or steroid injection for a
total cost-sharing of $282.40. The record indicates that the rendering provider is a neurology specialist.
Onabotulinumtoxina injections and anesthetic agent(s) and/or steroid injections fall within the Medicare Part B
Prescription Drugs and Physician/Practitioner Services, Including Doctor's Office Visits 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 and copayment for an onabotulinumtoxina injection (J0585)
and an anesthetic agent(s) and/or steroid injection (64405) provided on June 23, 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 the requested admission to an IRF does not meet
criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 you do not require treatment by multiple therapies, including either physical therapy
or occupational therapy, and an intensive rehabilitation therapy 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits.
You asked the Plan to pre-approve 6 additional PT visits. You say that the requested additional PT visits are medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 6 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had prior therapy approved and has not used all of the approved therapy yet. The enrollee has been approved for 24 visits that expand through November 05, 2021, to May 04, 2022. The visit on November 10, 2021 indicates the enrollee has only had 6 of the approved visits so far. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from September 22, 2020, to October 1, 2020, and billed with DRG (diagnosis related group) 441.
You asked the Plan to pay for inpatient care. You say that the billed DRG was correct. The Plan denied your request. The Plan says diagnosis K86.90 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 DRG 441, disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with major complications or comorbidities.. 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 inpatient care. Our reviewer says that the billed DRG is not supported. Our physician reviewer found the records do not support the diagnosis of pancreas disease (K86.90). 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 inpatient care provided from September 22, 2020, to October 1, 2020, and billed with DRG (diagnosis related group) 441
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 you do require physical therapy and occupational therapy services but based on
the medical records provided you do not require an intensive inpatient rehabilitation therapy program. Care at
the skilled nursing facility level appears to be appropriate in this case.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after November 14, 2021.
You asked the Plan to pre-approve SNF care. You say that you should continue your care. The Plan denied your request. The Plan says the denial of authorization for continued SNF care after November 14, 2021.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after November 14, 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. The Plan denied your request. The Plan says the enrollee does not
require an interdisciplinary team approach for rehabilitation 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 physician reviewer found
that the enrollee was admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Her
medical problems are stable. She does not require treatment by multiple therapies in an intensive rehabilitation
therapy program. While she has a need for physical and/or occupational therapy, there is no documentation of a
need for an intensive rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from
August 13, 2020, to October 9, 2020.
You asked the Plan to pre-approve a continued psychiatric admission. You say that the continued inpatient
psychiatric stay was medically necessary. The Plan denied your request. The Plan says the enrollee could have
been safely treated in a less intensive setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 continued psychiatric admission. Our
reviewer says that the continued inpatient psychiatric admission from August 13, 2020, to October 9, 2020, was
not medically necessary. Our physician reviewer found that the health plan's denial of continued inpatient
psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond
the dates in question as he was not a danger to himself or others and did not have any delusions, auditory or
visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did
not appear that the services for the dates in question were reasonably expected or medically necessary to
improve the enrollee's condition or for the purpose of diagnosis. It appears that the services were supervised
and evaluated by a physician. Based upon review of the records provided, this enrollee does not meet the
criteria for treatment in an acute inpatient mental health treatment beyond the date in question of August 13,
2021, forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or
homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or
aggression being cooperative and compliant while not showing any acute threats to safety.
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 continued psychiatric admission have not been met. Therefore, we decided
that the Plan does not have to pre-approve a continued inpatient psychiatric admission from August 13, 2020,
to October 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot x-ray provided on July 26, 2021.
You asked the Plan to pay for the foot x-ray. The Plan denied your request. The Plan says this is not a covered
service.
The Plan must follow Medicare rules. The rules say that services or devices directed toward the care or
correction of "flat foot", including the prescription of supportive devices, are not covered.
The records do not show that x-ray was provided for the diagnosis of "flat foot". Services provided for the care
or correction of "flat foot" are not covered. Therefore, we decided that the Plan does not have to pay for the
foot x-ray provided on July 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for eight (8) additional routine transportation trips (A0120).
You asked the Plan to provide coverage for additional routine transportation. You say that you have appointments scheduled for December and it is critical that you keep these appointments as you are in a lot of pain. The Plan denied your request. The Plan says you have exhausted the maximum benefit of 60 one-way trips per year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.
We looked at your request, the records in the case file, and the rules. The records show that you have used 60 one-way transportation trips this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for eight (8) additional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for endodontic therapy, anterior tooth provided by a participating provider on August 19, 2021.  You asked the Plan to pay for endodontic therapy. You say that you wanted to keep your tooth, so you had a root canal. The Plan denied your request. The Plan says the dental work provided was not medically necessary.  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 endodontic therapy 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 pay for endodontic therapy. Our reviewer says that these services were not medically necessary. Our physician reviewer found given the overall integrity of the upper arch, it appears that a removable appliance would be the least costly option. The Plan criteria therefore for overall treatment has not been met, and the treatment requested is not medically necessary.  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 endodontic therapy have not been met. Therefore, we decided that the Plan does not have to pay for endodontic therapy, anterior tooth provided by a participating provider on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (81292, 81295, 81298, 81317) provided on October 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed units are inappropriate.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT codes 81292, 81295, 81298, and 81317 is 1. The MAI value for these codes is 2. You billed 3 units of each of these codes, exceeding the MUE. 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 services (81292, 81295, 81298, 81317) provided on October 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one occupational therapy (OT) visit, four skilled nursing (SN) visits, and 16 home health aide (HHA) visits.
You asked the Plan to pre-approve the home health visits. You say that you would like reconsideration because the requested Home Health services are medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested home health services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the home health visits. Our reviewer says that you do not have documented skilled nursing needs. The documentation is insufficient to show that your wounds have improved with prior care or that ongoing care is medically necessary. Our physician reviewer found you do not have any documented skilled therapy needs. You are dependent for mobility and Activities for Daily Living. Your care needs appear to be custodial and long-term. As such, the requested, ongoing, Home Health services are not medically necessary or reasonable. 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 home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve one occupational therapy (OT) visit, four skilled nursing (SN) visits, and 16 home health aide (HHA) visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services (99601 and 99602) provided on
February 12, 2021.
You asked the Plan to pay for the home infusion services. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says CPT codes 99601 and 99602 have a
status indicator of I and are not valid for Medicare purposes.
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 find that CPT codes 99601 and 99602 are not supported in the record. Specifically, per the Physician Fee
Schedule, CPT codes 99601 and 99602 have a status indicator of I. This means that CPT codes 99601 and
99602 are not valid for Medicare purposes.
Based on this information, we decided that Medicare rules for coverage of the home infusion services have not
been met. Therefore, we decided that the Plan does not have to pay for the home infusion services (99601 and
99602) provided on February 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency
transport (A0427) and ground mileage (A0425) provided on May 28, 2020.
You asked the Plan to pay for the transportation services. You say that the enrollee was transported in an
emergency situation. You say that insurance information was not able to be provided at the time of service.
You also say that the delay was caused by the additional time needed to obtain the enrollee's correct insurance
information. The Plan denied your request. The Plan says the claim was not received within the 12-month
timeframe. The Plan also says that claims that are not received in the timeframe will be denied.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the transportation services was not filed until August 6, 2021. This means
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency
transport (A0427) and ground mileage (A0425) provided on May 28, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate.
You asked the Plan to pre-approve Methotrexate. You say that the medication is necessary. The Plan denied
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Methotrexate.
Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.