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. 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 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the enrollee feels they should be able to stay in the SNF for longer. The Plan denied your request. The Plan says that the requested 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 SNF care. Our reviewer says that the requested SNF care is medically necessary. Our physician reviewer found the provided documentation shows that the enrollee has skilled nursing needs, in the form of daily wound care. The enrollee has skilled therapy needs, as she is functioning below her baseline. Therefore, the reviewer found that a brief period of skilled services is reasonable to establish a maintenance program, prevent deterioration of the enrollee's condition and/or return the enrollee to her prior level of function. 

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 care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.

Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ostomy supplies coded A4421 provided on January 5, 2021.

You asked the Plan to pay for the ostomy supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that ostomy supplies are covered for certain indications. 

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 ostomy supplies. Our reviewer says that the documentation does not support that the items rendered were medically reasonable or necessary. Our physician reviewer found the enrollee has a history of rectal cancer. There is no specific documentation indicating the requested ostomy supplies are medically necessary. The documentation does not support that the enrollee had specific diagnosis/condition that meets criteria for the ostomy supplies provided. Therefore, the items rendered are not payable. 

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 ostomy supplies have not been met. Therefore, we decided that the Plan does not have to pay for the ostomy supplies coded A4421 provided on January 5, 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 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 does 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. 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) services coded 95955, the Needle electromyography coded 95885, and the nerve conduction studies coded 95908 provided on December 23, 2020.
You asked the Plan to pay for the electroencephalogram (EEG) services, the Needle electromyography, and the nerve conduction studies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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 find that CPT codes 95955, 95885, and 95908 are not supported in the medical record. Specifically, the technical report did not include documentation of an electroencephalogram (EEG) during nonintracranial surgery (carotid surgery); therefore, code 95955 cannot be verified. The technical report did not include documentation of a limited needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; (listed separately in addition to code for primary procedure); therefore, code 95885 cannot be verified. The technical report did not include documentation of nerve conduction studies; for 3-4 studies; therefore, code 95908 cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the electroencephalogram (EEG) services, the Needle electromyography, and the nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) services coded 95955, the Needle electromyography coded 95885, and the nerve conduction studies coded 95908 provided on December 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for treatment with Testopel testosterone pellet provided on February 17, 2021.

You asked the Plan to waive the coinsurance for Testopel. You say that the treatment at issue was best for your medical condition and that your provider was advised by a representative of the Plan that there would be no charge to you. 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 20% coinsurance for Medicare-covered Part B Chemotherapy drugs and other Part B drugs. 

You have been asked to pay $288, or 20% of the Medicare-allowed charge of $1,440, for Testopel. Testopel 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 treatment with Testopel testosterone pellet provided on February 17, 2021.

Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibility from a representative of the Plan 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear coded 85060 provided on February 18, 2021.

You asked the Plan to pay for the blood smear. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by physician with written report.

We find that CPT code 85060 is not supported in the medical record. Specifically, this code was billed with place of service 22 (On Campus-Outpatient Hospital). Code 85060 has a professional component/technical component indicator of 8. This value identifies the only payment made for the professional component of the code is for hospital inpatient. Based on this information, we decided that Medicare rules for coverage of the blood smear have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear coded 85060 provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on April 28, 2021.

You asked the Plan to pay for the services provided. You say that you received an estimate for what the plan would cover. The Plan denied your request. The Plan says the claim processed correctly.

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 file shows that adjunctive testing (D0431), gingival irrigation (D49210, and medicaments for home use (D9630) was provided. Although the Plan offers a dental benefit in excess of Medicare coverage, the services are not among those covered under this benefit.

The file shows that a comprehensive oral exam and complete series of x-rays were provided. We looked at the file, and Medicare rules. These services were last received on January 22, 2020. Your plan only covers these services once every 3 plan years. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services provided on April 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 11, 2020.

You asked the Plan to pay for the services provided. You say that the enrollee was not in hospice on the date of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on August 9, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 11, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on May 22, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 drug testing services provided on May 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a FoundationOne Liquid Biopsy (0239U) provided on March 3, 2021.

You asked the Plan to pay for a FoundationOne Liquid Biopsy. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this test was not ordered by the physician.

The Plan must follow Medicare rules. Medicare rules say that clinical laboratory services must be ordered and used promptly by the physician who is treating the beneficiary or by a qualified non-physician practitioner. 

We looked at the file and Medicare rules. The records show that the enrollee's treating physician ordered a FoundationOne Biopsy, which is a distinct service from the provided FoundationOne Liquid Biopsy. Based on this information, we decided that Medicare rules for coverage of a FoundationOne Liquid Biopsy have not been met. Therefore, we decided that the Plan does not have to pay for a FoundationOne Liquid Biopsy (0239U) provided on March 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for Lynch Syndrome.
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 services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that genetic testing for Lynch Syndrome is covered when specific criteria 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had BRCA1/2 genetic testing that is reported as negative. The enrollee's family history does not support a rationale for Lynch Syndrome testing. Lynch syndrome is associated with tumors/cancers include colorectal, endometrial, gastric, ovarian,pancreas, ureter and renal pelvis, biliary tract, brain (usually glioblastoma as seen in Turcotsyndrome), and small intestinal cancers, as well as sebaceous gland adenomas andkeratoacanthomas as seen in Muir-Torre syndrome. The enrollee does not have any of these cancers and none of the her colorectal polyps were
cancerous. The testing is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing for Lynch Syndrome
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve low vision services.

You asked the Plan to pre-approve the low vision services. You say that you would like reconsideration because you have a great desire to be independent and see the world again. The Plan denied your request. The Plan says that this is not a Medicare covered benefit.

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 one routine eye exam and eyewear once per calendar year. 

We looked at the file and the Plan's rules. The record clearly indicates that you have supplemental vision coverage for one routine eye exam and eyewear. Based on this information we decided that the Plan's rules for coverage of the low vision services have been met. Therefore, we decided that the Plan has to pre-approve low vision services.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-sterile gauze (A6216) provided January 21, 2020.
You asked the Plan to waive the copayment for non-sterile gauze. You say that you would like this coinsurance waived. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 durable medical equipment. You have been asked to pay a total cost share of $1.60 for non-sterile gauze ($8.00 Medicare-allowed amount x 20% coinsurance). This item falls within the durable medical equipment 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 non-sterile gauze (A6216)
provided January 21, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scans of the head/brain and abdomen/pelvis.
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 services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has renal cell carcinoma diagnosed in 2019. CT abdomen/pelvis was performed in June of 2021 showing slight increase in pulmonary nodules. Positron emission tomography (PET) showed pulmonary nodules remaining non-FDG and there was no evidence of recurrence in the abdomen. The enrollee is not reporting any worsening or changes in symptoms to suggest progression of the carcinoma in the head or abdomen/pelvic areas. Within three months and without localized symptoms, repeat imaging is not supported as it would likely not change the recommended treatment. Therefore, the CT abdomen and pelvis and the CT head will each be considered not medically necessary at this time. 
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 computed tomography (CT) scans of the head/brain and abdomen/pelvis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (99153) provided on March 18, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician in the facility setting. 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to pay for the anesthesia services (99153) provided on September 18, 2020. Therefore, we decided that the Plan does not have to pay for the anesthesia services (99153) provided on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 26, 2021 by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that your dentist bill was $150.00, and the Plan only paid an in-network benefit of $73.00. You also say that your dentist sent you a bill for $77.00 that you would like to be reimbursed for. The Plan denied your request. The Plan says the cost share was applied correctly per your plan benefits. The Plan also says that cost-sharing is a contractual obligation of the Plan and cannot be waived.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 26, 2021 by an OON provider.