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

 We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on June 3, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee is receiving appropriate care in the acute care hospital.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee was admitted for cystectomy to treat urothelial carcinoma and has had a prolonged hospital course. The record indicates that the enrollee continues to have abdominal infection and requires ongoing acute care services. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the specialist office visit provided on September 1, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that you were never informed of the copayment for the visit. 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 $25 copayment for each Medicare-covered specialist office visit.   You have been asked to pay a $25 copayment for the specialist office visit. The specialist office visit falls within the "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 copayment for the specialist office visit provided on September 1, 2021.   Your complaint that the physician's office committed fraud 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.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for SNF services provided from July 26, 2021, through August 24, 2021.  You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says SNF services were not medically necessary.  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 pay for SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, the enrollee did not qualify for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical matter, could be provided at a lower level of care (ex. home, assisted living, long term care).  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 services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from July 26, 2021, through August 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Rytary 95 mg capsule.  You asked the Plan to pre-approve Rytary. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 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 Rytary 95 mg capsule.   Benefits for Rytary 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 waive the coinsurance for the inpatient hospital admission and services provided July 28, 2021, to August 4, 2021, from an out-of-network (OON) provider.  You asked the Plan to waive the coinsurance for the inpatient hospital admission and services. You say that a plan representative told you the services would be covered. The Plan denied your request. The Plan says the coinsurance 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 40% coinsurance for each Medicare-covered hospital stay for unlimited days. You pay these amounts until you reach the OON out-of-pocket maximum of $10,000.  You have been asked to pay $10,000 for the inpatient hospital admission and services. The allowed amount for the inpatient services is $37,881.07. This means that 40% coinsurance is $15,152.43. However, this cost exceeds your out-of-pocket maximum. Therefore, you were charged your maximum OON amount of $10,000. The inpatient hospital admission and services fall within the inpatient hospital care benefit category. The Plan provided documentation which verifies that this provided is OON. 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 inpatient hospital admission and services provided July 28, 2021, to August 4, 2021, from an out-of-network (OON) provider.   Your complaint about the high cost-share and potentially being provided conflicting information from Plan representatives 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services provided from May 21, 201, to May 28, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis code 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 diagnosis code N17.9. 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 services. Our reviewer says that the use of diagnosis code N17.9 is not supported by the records provided. Our physician reviewer found that documentation indicates that the enrollee's provider stated that the renal function appeared to be at his baseline-creatinine 4.3/BUN 69 without any evidence of uremia. There was no documentation of acute kidney failure.   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 services provided from May 21, 201, to May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the subcutaneous tissue debridement (11042) provided on September 30, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $350 copayment for a Medicare-covered outpatient hospital stay for outpatient surgery.      You have been asked to pay a $325 copayment for the outpatient hospital surgery provided. This amount is less than the applicable copayment for this 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 the subcutaneous tissue debridement (11042) provided on September 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intravenous (IV) Actemra.  You asked the Plan to pre-approve IV Actemra. You say that this drug is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the IV form of Actemra is not supported for the enrollee's condition.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 IV Actemra. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found that the review indicates that the enrollee is a 74-year-old female with biopsy proven giant cell arteritis. Coverage for IV Actemra is provided for FDA-approved or non-FDA-approved medically accepted indications not otherwise excluded from coverage, such as rheumatoid arthritis (RA), systemic juvenile idiopathic arthritis (SJIA), cytokine release syndrome (CRS), and polyarticular juvenile idiopathic arthritis (PJIA). The review has determined that the requested use of intravenous Actemra is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals).  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IV Actemra have not been met. Therefore, we decided that the Plan does not have to pre-approve intravenous (IV) Actemra.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for a medical eye exam (92012) and an eye refraction (92015) provided on July 19, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay an additional amount for a medical eye exam and an eye refraction. You say that the exam and the refraction should be $0.00 for one non-Medicare covered routine vision exam including dilation and refraction as necessary. You also say you have never been charged for this before in the past. The Plan denied your request. The Plan says vision services with an OON provider are not covered. The Plan also says that the claim did however process correctly under your medical benefit, reflecting a specialist copayment and no coverage for the refraction.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you must use the Plan's specified routine vision provider for routine coverage including routine eye exam, retinal imaging and eyewear allowance. An eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider.  We looked at the file and the Plan's rules. The records show that the service at issue was provided by an OON provider. The EOC confirms this service is not covered by the Plan when provided by an OON provider. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. Please note, that the Plan processed your claim under your medical benefit. The EOC also confirms that $45 is the required copayment for this visit. Based on this information, we decided that the Plan's rules for coverage of a medical eye exam and an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay an additional amount for a medical eye exam (92012) and an eye refraction (92015) provided on July 19, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray services coded 73610 provided on June 24, 2021.  You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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 73610 is radiologic examination, ankle; complete, minimum of 3 views.  We find that CPT code 73610 is not supported in the medical record. Specifically, the submitted documentation supports one unit of this code, which was previously approved and paid by the Plan. There is no additional documentation supporting an additional study which was billed. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 73610 provided on June 24, 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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.  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 you were admitted for pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, 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: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the OON provider on July 21, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.    The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the OON provider on July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Aranesp (darbepoetin alfa) injection for the enrollee.  You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this drug is helpful for the treatment of iron deficiency anemia.  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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found Aranesp is not Food and Drug Administration (FDA) approved for treatment of iron deficiency anemia. Its use is not supported the guidelines or medical literature. The enrollee does not appear to be iron deficient at this time, and no other indications are met for use.  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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an Aranesp (darbepoetin alfa) injection for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on August 30, 2021.  You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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, we have confirmed that code 71045 is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to bypass the edit. 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 x-ray services coded 71045 provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for initial hospital care (99222) provided on April 4, 2021.  You asked the Plan to pay for initial hospital care. You say that this was billed correctly. The Plan denied your request. The Plan says the billed code is not appropriate.  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 99222 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.  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 initial hospital care. Our reviewer says that this code is not supported. Our reviewer found the medical records appear to reflect a consultation visit rather than the billed code.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care (99222) provided on April 4, 2021.