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

We decided that the Plan does not have to waive the copayment for the emergency room visit (99283) provided on May 26, 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 $90 copayment for each Medicare-covered emergency room visit. 

You have been asked to pay a $90 copayment for the Medicare-covered emergency room visit provided. 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 emergency room visit (99283) provided on May 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you have potential to make progress and may 
die if you go home because no one is there with you. The Plan denied your request. The Plan says , based on 
the enrollee's current level of function, he can safely receive the services needed in the current inpatient 
rehabilitation facility (IRF) setting. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, 
had stable vital signs, clear lungs, and was treated for pain. The enrollee received physical therapy, 
occupational therapy, and speech therapy. The enrollee is at a maximal assist to dependent level for bed 
mobility and transfers. The enrollee required varying assist with activities of daily living. The enrollee worked 
with a speech therapist on cognitive-linguistic and memory skills. There are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. 
The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an echocardiology stress test provided on July 19, 2021.

You asked the Plan to waive the copayment for an echocardiology stress test. The Plan denied your request. The Plan says application of a $275 copayment on the claim at issue was in accordance with the terms, conditions, and limitations in your Evidence of Coverage and that no additional benefits are owed on this claim.

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 $275 copayment for Outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $275 copayment for an echocardiology stress test. An echocardiology stress test falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an echocardiology stress test provided on July 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on January 20, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you have not gotten any answers 
regarding your condition so you do not believe you should be responsible for the copayment. 
 The Plan denied your request. The Plan says the claim was reprocessed, and 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 $50 
copayment for covered diagnostic radiology services in the outpatient department of a network hospital or 
facility.  
 
You have been asked to pay a $50 copayment for the CT scan. The CT scan falls within the "Outpatient 
diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the CT scan provided on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a surgical extraction (D7210) and an alveoloplasty with 
extraction (D7310) provided on April 1, 2021. 
 
You asked the Plan to pay for a surgical extraction and an alveoloplasty with extraction. You say that you 
disagree with the denial and would like the Plan to reconsider. The Plan denied your request. The Plan says 
your second quarter comprehensive dental benefit allowance was exhausted with additional services provided 
on April 01, 2021. 
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.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a surgical extraction and an alveoloplasty with extraction have not been met. Specifically, the 
comprehensive benefit allowance was exhausted with the additional dental services provided on April 1, 2021. 
Therefore, we decided that the Plan does not have to pay for a surgical extraction (D7210) and an alveoloplasty 
with extraction (D7310) provided on April 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Adcetris.
You asked the Plan to pre-approve Adcetris. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for this drug is correct, because the submitted
diagnosis of angioimmunoblastic T-Cell lymphoma that is not CD30-expressing is not a medically accepted
indication for Adcetris.
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 Adcetris. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested use of Adcetris. Our physician reviewer found
this use of Adcetris is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. Approval
is for the treatment of previously untreated CD30-expressing peripheral T-cell lymphomas (PTCL), including
angioimmunoblastic T-cell lymphoma and PTCL not otherwise specified. The enrollee's tumor is CD30
negative. This use of Adcetris is not supported by one of the major drug compendia or by clinical research
appearing in a Medicare-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 Adcetris have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Adcetris.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood pressure monitor provided on February 24, 2021 by a 
provider who is not enrolled in Medicare. 
 
You asked the Plan to pay for the blood pressure monitor. You say that the service should be covered. The Plan 
denied your request. The Plan says a provider or supplier must be enrolled in Medicare to receive payment. 
 
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. A provider or supplier must be enrolled in Medicare to receive 
payment.  
 
The requested provider in this case is not enrolled with the Plan. The Plan had network providers available who 
could have provided the items/services at issue in this appeal.  
The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for a blood pressure 
monitor provided on February 24, 2021 by a provider who is not enrolled in Medicare.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is 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 pre-approve these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the submitted records show that you 
underwent gastric bypass surgery. You have stable vital signs and received physical and occupational therapy 
in the hospital. You need assistance with functional mobility and activities of daily living. You have no skilled 
nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical 
matter, you do not require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on April 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the submitted records do not support the billing of procedure code 63082-76. 
 
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 63082 is vertebral corpectomy (vertebral body resection), 
partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each 
additional segment (List separately in addition to code for primary procedure). 
 
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 these services. Our reviewer says that the submitted records 
do not support the billing of procedure code 63082-76. Our reviewer found the submitted records do not 
include sufficient documentation to support that code 63082-76 was performed for the billed date of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the surgical services rendered on April 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transportation services provided on April 7, 2021.

You asked the Plan to pay for the non-emergent ambulance transportation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 non-emergent ambulance transportation services. Our reviewer says that the documentation does not support that the rendered transportation services were medically reasonable or necessary. Our physician reviewer found the enrollee received ambulance transportation to a doctor's office appointment. The documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for this enrollee on April 7, 2021.

Supervision would have been possible with stretcher van. The documentation shows that the enrollee was stable and did not require treatment during transport for this non-emergent office visit. Therefore, the enrollee did not meet criteria for the services rendered. 

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 non-emergent ambulance transportation services have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transportation services provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on
April 30, 2021.
You asked the Plan to pay for the drug testing. You say that the medical records support the need for this testing. The Plan denied your request. The Plan says this was not billed with an appropriate POS code.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on April 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on April 5, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 27310 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 27310 (exploration of knee joint) and 27488 (removal of knee prosthesis). Code 27310 is a column II code with a modifier indicator of 1 when billed with column I code 27488. Code 27310 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on April 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is 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 pre-approve these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was treated for colitis and 
had stable vital signs. She received physical and occupational therapy and is independent to contact guard assist 
level with functional mobility, including gait. She needs varied assistance with activities of daily living. She 
has no skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. 
As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level 
of 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from March 11, 2020, through March 17, 2020, billed with code IAID1.
You asked the Plan to pay for the SNF services as billed. You say that the correct assessment form was submitted with the appeal. You believe that the functional scores reported are correct and support the HIPPS code billed. The Plan denied your request. The Plan says there is no documentation of respiratory failure or cirrhosis, and the usual functional level during the first three days of the stay is inadequately documented.
The Plan follows Medicare rules. Medicare rules say that SNF services are billed using a HIPPS code which has four digits for four case-mix groups as described in the Medicare rules section.
Calculation of the proper HIPPS code takes into account the Resident Assessment Instrument (RAI) manual and PDPM calculation worksheet, which provides guidance on completing the Minimal Data Set (MDS) assessment. Reported diagnoses in Section I of the MDS assessment are used to help determine both the nursing case-mix group (third digit of the HIPPS code) and NTA case-mix group (fourth digit). The presence of acute respiratory failure as an active diagnosis would cause the nursing case-mix group to change from the Special Care: Low category to the Clinically Complex category. In addition, respiratory failure and cirrhosis would increase the NTA score into a higher-level case-mix group. 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 SNF services as billed. Our reviewer says that the documentation does not support the diagnoses of acute respiratory failure of cirrhosis of the liver as documented in Section I of the MDS assessment. Our physician reviewer found no documentation was received showing the physician identified respiratory failure, acute respiratory failure with hypoxia, or cirrhosis as diagnoses during the 60-day lookback period. No documentation received to support cirrhosis or respiratory failure as an active diagnosis within the last 7 days. We looked at this physician's review, the file, and Medicare rules. Since these diagnoses are not supported, both the third and fourth digits billed of the billed HIPPS code are not supported. Based on this information, we decided that Medicare rules for coverage of the SNF services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from March 11, 2020, through March 17, 2020, billed with code IAID1.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services (92014, 92083) provided on April 30, 2021.

You asked the Plan to pay for the vision services. You say that you were out of state when your glasses broke and needed a replacement. The Plan denied your request. The Plan says even though the enrollee was out of state there was still network providers available to provide these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items and services at issue in this appeal. The Plan did not pre-approve the items and services at issue.

We found no exception that would require the Plan to pay for these items and services. Therefore, we decided that the Plan does not have to pay for vision services (92014, 92083) provided on April 30, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia. 
 
You asked the Plan to pre-approve Orencia. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says step therapy criteria have not been met. 

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Orencia. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates 
that the enrollee has rheumatoid arthritis. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia.