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

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested level of care is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the requested inpatient level of care is not medically reasonable and necessary in this case. Our physician reviewer found that inpatient admission is not required for routine shoulder arthroplasty surgery. The procedure may be safely performed with a 48-hour observational stay.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.
You asked the Plan to pre-approve Ondansetron. You say that the enrollee is not undergoing chemotherapy.
You also say that the requested drug is medically necessary. The Plan denied your request. The Plan says the
requested drug is considered self-administered. The Plan says self-administered drugs are covered under a
Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare
Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.
Benefits for Ondansetron 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient (92012) and prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia (92310) provided October 8, 2021.  You asked the Plan to pay for the medical eye exam and contact lens fitting. You say that this provider was in-network last year. The Plan denied your request. The Plan says these services are not covered because the provider has opted out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient (92012) and prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia (92310) provided October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 14, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for an office visit. You say that the enrollee was referred to you as a new patient and
there was no knowledge of an authorization being needed. The Plan denied your request. The Plan says the
rendering provider is a non-participating provider without prior authorization. There was also no in-network
referring provider for this service. The service was also not urgent or emergent.
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/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 an office visit provided on July 14, 2021, by an
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive the copayment for inpatient rehabilitation services provided from
December 30, 2020, to January 28, 2021.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you feel that
you are being charged twice for the same inpatient stay. The Plan denied your request. The Plan says that you
have been charged the correct cost sharing amount.
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information
to the Independent Review Entity (IRE).
Specifically, the Plan has not forwarded a copy of their 2020 Evidence of Coverage (EOC). Without this
contract information, we are unable to verify the cost share amounts applied to the services received. It is the
burden of the Plan to substantiate their denial with evidence. In this case, the Plan's denial is not substantiated,
so we must find in your favor. Therefore, we decided that the Plan has to waive the copayment for inpatient
rehabilitation services provided from December 30, 2020, to January 28, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a vitamin B-12 injection provided on April 22, 2021.

You asked the Plan to waive the coinsurance for the injection. You say that you are on a limited income and cannot afford the charges. The Plan denied your request. The Plan says the correct coinsurance was applied.

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 Part B drugs and administration, including injectable drugs.

You have been asked to pay $3.61, which is 20% of the allowed amount for the injection. The injection falls within the Medicare Part B Prescription Drugs 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 for a vitamin B-12 injection provided on April 22, 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.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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. Our
physician reviewer found the enrollee appears to be somewhat unstable but without expected long-term
complex care needs and requires only short-term additional acute care services that can be administered safely
at the current facility. There are no services at the LTACH that the enrollee requires that are not already
available at the current facility. Transfer to a lower level of care may be considered when treatment has
completed and the enrollee is more stable.
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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services (CPT code 99153) provided
to the enrollee on February 27, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the claim denial was applied correctly per Medicare billing guidelines CPT code 99153
has a Professional Component (PC)/Technical Component (TC) indicator of 3 per the 2021 National Physician
Fee Schedule Relative Value File.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. CPT code had a PC/TC indicator of three (3),
for a technical component only code as defined in the Medicare Claim Processing Manual, Chapter 26, in the
50.6-Physician Fee Schedule Payment Policy Indicator File Record Layout. As CPT code 99153 is a technical
component only code, it should be reported by a MAC Part A or B hospital setting. The enrollee was in the
emergency room on February 27, 2021. Therefore, we find the Medicare rule for payment of this claim has not
been met. If the provider determines that a billing error occurred during the initial submission of the denied
claim, the plan will accept a submission of a corrected claim to consider services for payment. 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 moderate sedation services (CPT code 99153) provided to the
enrollee on February 27, 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 the intensive rehabilitation therapy program provided in an
inpatient rehabilitation facility. Care at the skilled nursing facility level or in the home with home health
services appear 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care services you received from a
nurse practitioner at an outpatient hospital facility on September 10, 2021.
You asked the Plan to waive the copayment for the wound care services. You say that you feel as though you
are being double-charged for this service. The Plan denied your request. The Plan says you were charged this
copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30
copayment for wound care at an outpatient hospital facility.
You have been asked to pay a $30 copayment for the wound care services. 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 wound care services you received from a nurse
practitioner at an outpatient hospital facility on September 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for individual psychotherapy services (90832) provided October 6, 2021.
You asked the Plan to pay for the psychotherapy services. You say that the enclosed medical records clearly
reflect the medical necessity for the services rendered. The Plan denied your request. The Plan says that service
not supported without required documentation.
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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the psychotherapy services have been met. The submitted claim includes a referring provider for
the services at issue. Documentation of a physician consultation does not apply when the physician has referred
the beneficiary to the clinical psychologist. Therefore, we decided that the Plan has to pay for individual
psychotherapy services (90832) provided October 6, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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. Our physician reviewer found the enrollee appears to be somewhat unstable but without complex care needs and requires only short-term additional acute care services including attempts at vent weaning that can be administered safely at the current facility. There are no services at the LTACH that the enrollee requires that are not already available at the current facility. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.   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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Auryxia Tablet, 210 mg.
You asked the Plan to pre-approve Auryxia. You say that this drug is medically necessary. The Plan denied
your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not
covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Auryxia Tablet, 210 mg.
Benefits for Auryxia 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial upper denture (D5213), a partial lower denture (D5214) and a consultation for a diagnostic service provided by dentist or physician (D9310) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve dental services. You say that you have been working with your dentist for nearly 2 years to get upper and lower dentures and you still do not have dentures that fit your mouth properly. You are unable to chew with the dentures provided and have lost weight. You also say that there is not a prosthodontist in your network. The Plan denied your request. The Plan says you must use network providers to receive dental services. The only exceptions are emergencies and urgently needed care. Dental services may be covered when they are provided by a participating Plan dental provider.    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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213), a partial lower denture (D5214) and a consultation for a diagnostic service provided by dentist or physician (D9310) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Esophagogastroduodenoscopy services (43251 and 43239) provided on October 1, 2021.  You asked the Plan to pay for the Esophagogastroduodenoscopy. You say that you would like reconsideration because these codes were billed with a modifier to indicate that they were separate and distinct. The Plan denied your request. The Plan says these services are bundled and 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.  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 Esophagogastroduodenoscopy. Our reviewer says that CPT codes 43251 and 43239 do not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report describes an Upper GI endoscopy with a tumor removal with a hot snare.  In this case billing CPT 43251 and CPT 43239 together is inappropriate, and not supported by modifier 59.  In this case a Esophagogastroduodenoscopy with biopsy and removal of tumor was performed.  The highest value procedure should be reported in this case.  The rules say that if Field 21 contains an indicator of "3," and multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy.  You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, 40.6c  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 Esophagogastroduodenoscopy have not been met. Therefore, we decided that the Plan does not have to pay for the Esophagogastroduodenoscopy services (43251 and 43239) provided on October 1, 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 the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level or in the home with home health services 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.