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

We decided that the Plan does not have to pay for the inpatient hospital services provided from July 7, 2020,
through July 9, 2020, billed with secondary diagnosis code G93.41.
You asked the Plan to pay for the inpatient services as billed. You say that this claim was billed correctly. The
Plan denied your request. The Plan says the secondary diagnosis G93.41 is not supported, which reduces DRG
payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with secondary diagnosis codes G93.41, defined as
Metabolic encephalopathy. 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 inpatient
services as billed. Our reviewer says that the reported secondary diagnosis code G93.41 is not supported in the
records. Our physician reviewer found Discharge summary does not have this diagnosis and treatment
documented in the discharge summary. Hospital discharge summaries serve as the primary documents
communicating a patient's care plan to the post-hospital care team. Components of a hospital discharge
summary is reason for hospitalization, significant finding, procedures and treatment provided, patient's
discharge condition, patient and family instructions (as appropriate) and attending physician's signature. There
is no supporting documentation of treatment for this diagnosis, therefore, it cannot be confirmed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital services provided from July 7, 2020, through July 9, 2020, billed with secondary
diagnosis code G93.41.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided on July 21, 2021.
You asked the Plan to pay for therapeutic activities. You say that the services are necessary. The Plan denied
your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.
We asked our coding 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 therapeutic activities. Our reviewer says that
the services are not supported by the medical records. Our coding reviewer found the medical records
document that the service was performed in a home health or hospice setting. 97530 is not the most appropriate
code to represent the service performed. There is a more appropriated Healthcare Common Procedure Coding
System code to use to bill this service, therefore, this service is not eligible for reimbursement consideration.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of therapeutic activities have not been met. Therefore, we decided that the Plan
does not have to pay for therapeutic activities (97530) provided on July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the enrollee has breast cancer with bone metastasis
which is elevated progressive disease. The Plan denied your request. The Plan says the denial of authorization
for this drug is correct, because the enrollee does not have the form of breast cancer for which Keytruda has
shown benefit. 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 Keytruda. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested use of Keytruda. Our physician reviewer found
the record indicates that the enrollee has a diagnosis of Stage IV breast cancer with bone metastasis, ER/PR
positive, and HER2 elevated. The Food & Drug Administration (FDA) has not stated that Keytruda is indicated
for this condition. This request is not supported by Medicare-approved 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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Keytruda.
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 IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of IRF 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. Our physician reviewer found that 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 a 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.
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. You say that IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of IRF 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. Our physician reviewer found 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. 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: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 1,
2020, through May 6, 2020, billed with code KAKE1.
You asked the Plan to pay for the SNF care as billed. You say that this meets the manual guidelines for
reporting isolation because of the prevalence of COVID-19 during this time, and the need to take droplet
precautions. The Plan denied your request. The Plan says this HIPPS code is not correct as the criteria for
reporting isolation are not met.
The Plan must follow Medicare rules. Medicare rules say that selection of the HIPPS code under PDPM is
based on information reported on the 5-day assessment. Reporting isolation is allowed only when the criteria in
the Medicare rules section are met.
We find that the criteria for reporting isolation are not met in this case. The documentation shows that the
patient tested negative for COVID-19, and there was no positive test for any other "highly transmissible or
epidemiologically significant pathogens". Although the enrollee was correctly isolated, this does not meet the
criteria for reporting this for SNF billing purposes. Therefore, we decided that the Plan does not have to pay for
the skilled nursing facility (SNF) care provided from May 1, 2020, through May 6, 2020, billed with code
KAKE1.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ultrasound of the head and neck you had on June 21, 2021.
You asked the Plan to reduce the copayment for the ultrasound. You say that when you had this test in 2020, you paid nothing with a different insurer. You stated that you would like to have only a $25 copayment. 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 an $85 copayment for radiological diagnostic services. You have been asked to pay an $85 copayment for the ultrasound. The ultrasound falls within the radiological diagnostic services benefit category. This copayment applies regardless of what you may have paid with a
previous insurer. 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 reduce the copayment for the ultrasound of the head and neck you had on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June
28, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you decided to change dentists
because you were unhappy that the previous provider billed you an extra $100 after you had already paid half.
You also say that You also say that you believe this service should be covered because the exam was with a
new dentist. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your
benefit plan.
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, comprehensive oral evaluation
(D0150) is limited to one procedure every three plan years. The record shows that you received a
comprehensive oral evaluation (D0150) on December 21, 2020 and your comprehensive oral evaluation
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation (D0150) provided on June 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided January
1, 2021 to January 5, 2021.
You asked the Plan to pay for the SNF services. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services received by the enrollee were 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 pay for the SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and
ophthalmic medications. The enrollee had stable vital signs. The enrollee was monitored for falls. The enrollee
required maximal assistance of two level with functional posture. The enrollee worked with occupational
therapy with wheelchair mobility. The documentation does not support that the enrollee required skilled
nursing or skilled therapy services on a daily basis.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for the skilled nursing facility (SNF) services provided January 1, 2021 to January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on May 7, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you specifically went to the doctor for an annual wellness exam, so there should be no copayment. The Plan denied your request. The Plan says it has waived the office visit copayment, but you are still responsible for the lab copayment. The Plan says that because the allowed amount for the lab services ($3.48) is less than your copayment obligation, you are responsible for the full allowed 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 $10 copayment for lab services. You have been asked to pay a $10 copayment for the lab services. Annual physicals do not include lab services, so separate cost sharing can apply for that. 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 lab services you received on May 7, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Opdivo for the enrollee.
You asked the Plan to pre-approve Opdivo. You say that Opdivo is medically reasonable and necessary for the
enrollee. The Plan denied your request. The Plan says that that the clinical value and effectiveness of Opdivo in
the setting of tumor progression while on therapy with a checkpoint inhibitor (Keytruda) has not been
demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Opdivo. Our reviewer says that Opdivo
is medically reasonable and necessary for the enrollee. Because Opdivo was authorized previously, its
continuation must be approved with response provided on the July 2021 scan. The enrollee's previous regime
with Opdivo began in May of 2021. Our physician reviewer found that the enrollee's condition meets criteria
for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Opdivo have been met. Therefore, we decided that the Plan has to pre-approve
Opdivo for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Jazzy Select power scooter to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a Jazzy Select power scooter to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says that they have in-network suppliers who can provide a power scooter that includes a power elevating seat.
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. 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 Jazzy Select power scooter to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular interim partial denture (D5821) provided on April 29, 2021.
You asked the Plan to pay for the mandibular interim partial denture. You say that this service should be covered by your insurance. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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, 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 mandibular interim partial denture (D5821) provided on April 29, 2021.
Your complaint about your dissatisfaction with 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August
1, 2019, through August 9, 2019, billed with Resource Utilization Group (RUG) code RHC.
You asked the Plan to pay for the SNF services as billed. You say that the records support the coding. The Plan
denied your request. The Plan says there is no 14-day assessment meaning that the default AAA rate is paid for
these dates.
The Plan must follow Medicare rules. Medicare rules say that SNF PPS payment is made based on scheduled
assessments, including the 14-day assessment, which pays for days 15-30 of the stay. The default rate is paid
for SNF dates outside of compliance with a scheduled assessment.
The enrollee was admitted to this SNF stay on July 8, 2019. This means that the scheduled 14-day assessment
is required to control payment for dates July 23, 2019, through August 8, 2019. There is no full 14-day
assessment included in the file submitted. As such, the payment as correctly reduced to the default rate for the
dates on this claim. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility
(SNF) care provided from August 1, 2019, through August 9, 2019, billed with Resource Utilization Group
(RUG) code RHC.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on June 16, 2021.
You asked the Plan to pay for the bitewing x-rays. You say that you believe the previous x-rays were taken when you had the additional dental rider. The Plan denied your request. The Plan says the frequency limit for this service has been exceeded.
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, bitewing x-rays are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0274) on May 24, 2021 and your bitewing x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on June 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Verio test strips, a non-preferred test strip
brand.
You asked the Plan to pre-approve a non-preferred test strip brand. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says the services are available from the
preferred providers.
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers
for durable medical equipment and supplies.
We looked at the file, the Plan's contract and Medicare rules. The services at issue are diabetic testing strips
from a non-preferred provider. The services are available from the Plan's preferred providers. Therefore, we
decided that the Plan does not have to pre-approve OneTouch Verio test strips, a non-preferred test strip brand.
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 IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of IRF 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. Our physician reviewer found that 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 a 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. 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.