Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from October 8, 2020, to October 28, 2020.  

You asked the Plan to waive the copayment for the inpatient stay. You say that this bill for the enrollee was received after he passed away, and you are not supposed to be liable for paying this bill. The Plan denied your request. The Plan says this copayment was assessed in accordance with the contract. The services at issue were medically necessary and provided to the enrollee at the time.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment for each of the first six days of an inpatient stay.   

The enrollee has been asked to pay a $1,800 copayment for the inpatient stay which exceeded six days ($300 x 6 = $1,800). This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from October 8, 2020, to October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (CPT code 97530) provided to the enrollee on August 24, 2020.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  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 service. Our reviewer found documentation submitted was reviewed and does not meet criteria. Occupational Therapy services were performed by a Certified Occupational Therapist Assistant in the home setting. Therapy visit documents patient is homebound. CPT 97530 is an inappropriate code to report for in home therapy services.  There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code that should be reported for therapy services performed in the home setting.  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 service have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (CPT code 97530) provided to the enrollee on August 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided April 21, 2021.  You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you should only be charged an emergency room copayment since you did not stay overnight. The Plan denied your request. The Plan says the copayment was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per hospital admission.  You have been asked to pay a $250 copayment for the inpatient hospital admission. The inpatient hospital admission, as billed, falls within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.   This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided April 21, 2021.   Your complaint about being admitted as an inpatient for this stay 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: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve therapeutic radiology simulation-aided field setting (77280).  You asked the Plan to pre-approve the therapeutic radiology simulation-aided field setting. You say that you would like reconsideration because the requested service is medically necessary to avoid surgery. The Plan denied your request. The Plan says that CPT 77280 is not required to deliver the recommended radiation.  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 therapeutic radiology simulation-aided field setting. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the code 77280 is to report simple simulation of a single treatment area. A treatment area is a contiguous anatomic location that will be treated with radiation therapy, which includes for this member the primary tumor location on her nose.  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 therapeutic radiology simulation-aided field setting have been met. Therefore, we decided that the Plan has to pre-approve therapeutic radiology simulation-aided field setting (77280).   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a crown (D2750).  

You asked the Plan to pre-approve the crown. You say that you have been a very loyal member of the Plan for years. You also say that you cannot understand the valid and legal reason of this denial The Plan denied your request. The Plan says your dental plan only covers services to treat problems directly caused by dental disease. The Plan also says that your records do not show this problem was caused by a type of dental disease.  

Medicare generally does not cover dental services. The Plan follows the same rule.  

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750).
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 IRF admission is not medically necessary based on lack of medical complexity and rehabilitation nursing needs. Document does not support the necessity for admission to IRF. While you may benefit from continued physical therapy (PT), and occupational therapy (OT), your rehabilitation needs can be safely met in an alternate and low intensity setting such as in an skilled nursing facility (SNF).  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 acute gastrointestinal blood loss imaging (procedure code 78278) provided to the enrollee on December 15, 2019.  You asked the Plan to pay for the imaging. You say that this should be paid for. The Plan denied your request. The Plan says there is no additional documentation supporting an additional study.  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 78278 is "Acute gastrointestinal blood loss imaging."  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 imaging. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the medical and billing records submitted indicate one unit of CPT 78278, which was previously paid. The medical records submitted does not include sufficient documentation to validate another unit of CPT 78278, therefore this procedure cannot verified.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the imaging have not been met. Therefore, we decided that the Plan does not have to pay for acute gastrointestinal blood loss imaging (procedure code 78278) provided to the enrollee on December 15, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a Latera implant (right side) for the enrollee.
You asked the Plan to pre-approve the implant. You say that this is needed for nasal obstruction. The Plan denied your request. The Plan says that there is not enough proof or research by specialists that describe the safety, value, or effectiveness for this procedure.
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 implant. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's diagnosis is nasal obstruction with dynamic nasal valve collapse. The treatment for this condition often includes surgery if the symptoms do not improve with medical management. The standard of care is to offer and perform surgery if the patient wishes. The surgery to address nasal valve collapse consists of both a traditional method using a cartilage graft and newer method with an absorbable implant. The Latera implant is FDA approved for this condition and is not considered experimental or investigational. The implant is necessary in this case in order to improve the enrollee's nasal obstruction and nasal breathing. It is not considered a cosmetic procedure and is meant to improve the functional breathing of the nose. 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 implant have been met. Therefore, we decided that the Plan has to pre-approve a Latera implant (right side) for the enrollee.
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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ramelteon for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary to treat the patient's insomnia. 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 Ramelteon 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.  You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is stable from recent illness, and does not meet the coverage criteria for this admission. With their current stability, and no medical complexity, there is no need for physician supervision three times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute rehabilitation needs noted in the record. At the current functional level, the enrollee does not require IRF level of therapies consisting of at least three hours of therapy per day, at least five days per week, with multidisciplinary approach to daily therapy. The enrollee has no ability to fully participate due to dementia. Needs can be met in an alternate and low intensity setting such as a SNF.  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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eyeglasses provided on August 12, 2021.   You asked the Plan to pay for the eyeglasses. You say that you purchased eyeglasses after your eye exam, and you were not aware of the 12-month requirement. The Plan denied your request. The Plan says you reached the maximum benefit for frames and lenses.  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 covers up to $150 every year for eyewear. This benefit is administered on a rolling calendar year since your last date of service.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Specifically, it had not been a year since you last purchased eyeglasses. Therefore, we decided that the Plan does not have to pay for the eyeglasses provided on August 12, 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 enrollee needs rehabilitation and physical therapy to learn how to walk and move around again. You say that the enrollee has been in the hospital bed for 24-hours a day. You say that there is no one who is able to assist the enrollee at home. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in other settings.  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 respiratory failure, sepsis and coronavirus pneumonia. 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve combination use of Opdivo and Yervoy.  You asked the Plan to pre-approve Opdivo and Yervoy. You say that this combination has been effective in this setting. The Plan denied your request. The Plan says the denial of authorization for this drug combination is correct, because studies have not proven that this combination is effective when the enrollee already tried a similar anti-PD-1 therapy and did not have a positive response.  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 and Yervoy. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested combination of Opdivo and Yervoy. Our physician reviewer found this combination is only a first-line regimen; however, this is being requested as a second-line after carboplatin/gemcitabine.  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 and Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve combination use of Opdivo and Yervoy.
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 for the enrollee.  You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can receive care in a different setting.  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.   The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a fall, pneumonia, deep vein thrombosis, and atrial fibrillation with rapid ventricular response. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Dexcom G6 Sensor.  You asked the Plan to pre-approve the Dexcom G6 Sensor. You say that the item is medically necessary. The Plan denied your request. The Plan says the member is not insulin treated with three or more daily injections of insulin.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.   We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the Dexcom G6 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 Sensor.