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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require
intensive therapy services 3 hours a day.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that you were admitted to the acute care hospital for a right foot infection and had a below the knee amputation.
Your medical problems are stable. You do not require treatment by multiple therapies in an intensive
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on April 24, 2021.

You asked the Plan to pay for the emergency department visit. You say that the enrollee had multiple services. The Plan denied your request. The Plan says this service is bundled to a paid service billed on the same day by a physician of the same specialty in the same billing group.

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 the emergency department visit has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 emergency department visit provided on April 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this request is medically necessary. The Plan denied your request. The Plan says the coverage criteria for this device have not been met as the enrollee is not on 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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Magnetoencephalography (MEG), recording and analysis (95965) provided on May 11, 2021.

You asked the Plan to pay for the MEG. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the professional interpretation must be separately billed with modifier 26.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 95965 is not supported in the record. Specifically, CPT code 95965 has been billed globally. Only the professional component may be paid to the physician as payment for the technical component is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the MEG have not been met. Therefore, we decided that the Plan does not have to pay for Magnetoencephalography (MEG), recording and analysis (95965) provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on March 16, 2021.

You asked the Plan to pay for the services provided. You say that the documentation supports the level of care billed for this enrollee. The Plan denied your request. The Plan says the billed code cannot be verified.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Critical care service is a time-based service. The records provided do not indicate how much time was spent with the enrollee on the date of service at issue. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services provided on March 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on September 10, 2020, to September 15, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says criteria was not met for inpatient admission.

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 pay for acute inpatient hospital care. Our reviewer says that it was not expected that the enrollee would require hospital services that would likely cross 2 midnights. Our physician reviewer found that based on the fact that the enrollee was hemodynamically stable before and after the procedure and treatment in the emergency department. A lower level of care would have been more appropriate. 

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 pay for the acute inpatient hospital care provided on September 10, 2020, to September 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the certolizumab pegol injection and the therapeutic injection provided on April 21, 2021.

You asked the Plan to waive the cost for the certolizumab pegol injection and the therapeutic injection. You say that you were told you had $0 responsibility and they did not collect a balance up front. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B and a $130 copayment for outpatient hospital services.

You have been asked to pay a total of $558.13 for the certolizumab pegol injection and the therapeutic injection.

The certolizumab pegol injection falls within the "Medicare Part B prescription drugs" benefit category. The therapeutic injection falls within the "Outpatient hospital services" 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 cost for the certolizumab pegol injection and the therapeutic injection provided on April 21, 2021.
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 this 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 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 non-surgical management of a pelvic fracture. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 is a high fall risk. The Plan denied your request. The Plan says the medical records do not support the ability to tolerate an intensive therapy program.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital for surgical treatment of a distal femur fracture. Her medical problems are stable. There is not a reasonable expectation that she will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an eye exam and eyeglasses provided on
March 23, 2021.
You asked the Plan to reimburse you for the eye exam and eyeglasses. You say that you checked numerous providers on the Plan's website to make sure the vision services were covered. The Plan denied your request. The Plan says the member does not have out-of-network benefits.
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 these services when provided by the Plan's vision provider. We looked at the file and the Plan's rules. The file shows that the vision services were not provided by the Plan's vision provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam and eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for an eye exam and eyeglasses provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laser hair removal.
You asked the Plan to pre-approve the laser hair removal. You say that this request should be considered medically necessary. The Plan denied your request. The Plan says cosmetic procedures are not covered.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. We looked at the file and Medicare rules. In this case, the requested procedure is not medically necessary as it is considered primarily cosmetic in nature. Based on this information, we decided that Medicare rules for coverage of the laser hair removal have not been met. Therefore, we decided that the Plan does not have to pre-approve the laser hair removal.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs rendered on March 25, 2021 to March 26, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you should not have to pay anything for outpatient surgery. 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 a 20% coinsurance for each Medicare-covered Part B drug.
Review of the file shows that you received Part B drug services on March 25, 2021 to March 26, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered Part B drug 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 the Part B drugs rendered on March 25, 2021 to March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pulse oximeter (E0445).
You asked the Plan to pre-approve a pulse oximeter. You say that this requested equipment is medically necessary. The Plan denied your request. The Plan says this device is not necessary as the enrollee is not on oxygen.
The Plan must follow Medicare rules. Medicare rules say that oximeters will be denied as non-covered because they are monitoring devices that provide information to the treating practitioner to assist in managing the beneficiary's treatment. We looked at the file and Medicare rules. In this case, the requested item is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a pulse oximeter have not been met. Therefore, we decided that the Plan does not have to pre-approve a pulse oximeter (E0445).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cold therapy pump (E0218) and a lambskin wool mattress pad (E0189) for use after knee surgery.
You asked the Plan to pre-approve the cold therapy pump and lambskin pad. You say that these items are needed. The Plan denied your request. The Plan says the Medicare criteria for these items are not met.
The Plan follows Medicare rules. Medicare rules say that cold therapy pumps are not considered medically reasonable and necessary. Group 1 pressure reducing surfaces are only covered when the criteria listed in the Medicare rules section are met. 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 cold therapy pump and lambskin pad. Our reviewer says that the Group 1 mattress overlay does not meet criteria for medical necessity. Our physician reviewer found this surface was requested for use after a total knee replacement. The provided documentation does not show that the patient was immobile and bed bound after the surgery, or that they were at high risk for decubitus ulcers during recovery. The wool skin was not supported in the documentation, as
other simple coverings (blanket) could be used without issue. Therefore, the wool skin will be considered not medically necessary. 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 cold therapy pump and lambskin pad have not been met. Therefore, we decided that the Plan does not have to pre-approve a cold therapy pump (E0218) and a lambskin wool mattress pad (E0189) for use after knee surgery.
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for seizures. Your 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 the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's needs
can be provided in a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that the enrollee was admitted to the acute care hospital for lower extremity swelling. He was diagnosed with
diffuse B cell lymphoma for which chemotherapy was started. He had gastrointestinal bleeding and received
blood transfusion for anemia. His medical problems are stable. The complexity of his nursing, medical and
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of an implant (D6010), interim
abutment (D6051) and radiographic/surgical implant index (D6190) provided on April 20, 2021.

You asked the Plan to pay for the dental implant services. You say that these services should be covered as oral
surgery. The Plan denied your request. The Plan says the services at issue are defined as dental implant services
and are not defined as oral surgery. Your dental benefit does not cover implant services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's dental benefit does
not cover implants and related services.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
surgical placement of an implant (D6010), interim abutment (D6051) and radiographic/surgical implant index
(D6190) provided on April 20, 2021.