Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for therapeutic phlebotomy (99195) provided on August 12, 2021.  You asked the Plan to waive the copayment for therapeutic phlebotomy. You say that you have never paid for phlebotomies in the past six years and would not be alive without them. The Plan denied your request. The Plan says the copayment you are being charged is correct.  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 $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.   You have been asked to pay a $99.52 copayment for therapeutic phlebotomy. The record shows the Medicare Allowed Amount is $99.52, which is lower than your copayment of $295 per the EOC. The EOC confirms that this is the required copayment for this service. Therapeutic phlebotomy falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 therapeutic phlebotomy (99195) provided on August 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral surgery for the enrollee.

You asked the Plan to pre-approve oral surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered by Medicare or the 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 pre-approve oral surgery for the enrollee.
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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.

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 record indicates that the enrollee is improving but still requires ongoing acute care services to complete his hospital course. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied; the requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: 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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 skilled nursing facility (SNF) services provided to the enrollee from July 25, 2021, to August 20, 2021.  

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there was no daily skilled nurse or therapist need.  

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment from 07/25/2021 through 08/20/2021. Daily skilled therapy services were not required (or provided) from 07/25/2021 through 08/20/2021. The services appear to be custodial in nature.  

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 services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from July 25, 2021, to August 20, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that that your records do not show that you require daily skilled services that can only be provided on an inpatient basis.  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 SNF care is medically reasonable and necessary. You do not have documented skilled nursing needs. You do have documented skilled therapy needs. You are improving but are functioning below your baseline. A period of daily skilled services is reasonable to establish a maintenance program and to prevent deterioration of your condition. Our physician reviewer found that your condition meets Medicare criteria for SNF 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 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the thoracic spine x-ray (72070) and lumbosacral spine x-ray (72100) provided on September 2, 2021.  You asked the Plan to pay an additional amount for the x-rays. You say that this provider is in network. You say that you received a bill for $95. You say that you were assured by a plan representative that the services would be covered. You also say that had you known they would not be covered, you would not have had the x-rays done. The Plan denied your request. The Plan says the cost share 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 $95 copayment for Outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay $95 copayment for the x-rays. The x-rays fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category under Basic Radiological 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 pay an additional amount for the thoracic spine x-ray (72070) and lumbosacral spine x-ray (72100) provided on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fillings for teeth # 24 and 25 provided on April 27, 2021.  

You asked the Plan to pay for the fillings. You say that these services should be covered. The Plan denied your request. The Plan says 2 restorations per consecutive 12 months are covered. The Plan also says that the frequency limit 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 and fillings are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for fillings on teeth # 22 and 23 that you received on March 24, 2021. Therefore, we decided that the Plan does not have to pay for the fillings for teeth # 24 and 25 provided on April 27, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray (71045) provided on September 5, 2021.  You asked the Plan to pay for the chest x-ray. You say that this date of service is after the termination of the enrollee's Hospice period and should be covered. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.  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 September 3, 2021. 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 chest x-ray (71045) provided on September 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an aflibercept injection (67028, J0178, 92134) provided on October 1, 2020, by an out-of-network (OON) provider.  

You asked the Plan to pay for an aflibercept injection. You say that your office did not obtain an authorization because you had no knowledge that the patient's insurance had changed since her previous appointment on August 26, 2020. The Plan denied your request. The Plan says there was no prior authorization, and the service was rendered by an out-of-network 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 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 aflibercept injection (67028, J0178, 92134) provided on October 1, 2020, 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 special anesthesia service (99100) provided on September 9, 2020.  You asked the Plan to pay for the special anesthesia service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99100 has a status indicator of B.  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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status indicator of B. This means that the payment for CPT code 99100 is always bundled into the payment for another service or procedure.  Based on this information, we decided that Medicare rules for coverage of the special anesthesia service have not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia service (99100) provided on September 9, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pay for treatment with Remicade (J1745) provided on April 29, 2021.  You asked the Plan to pay for Remicade. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Remicade. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of Inflectra before they will approve the requested drug. The requested drug is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step-one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from, the Plan's preferred step one alternative.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have to pay for treatment with Remicade (J1745) provided on April 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the breast ultrasound (76642) provided on September 14, 2021.  

You asked the Plan to pay for the breast ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 76642 has been billed in excess of the MUE.  

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   

In this case, the MUE for CPT code 76642 is 2. The MAI value for this code is 2. You billed 3 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the breast ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the breast ultrasound (76642) provided on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (G0483) provided December 18, 2020.  You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  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 G0483 is not supported in the medical record. Specifically, the place of service listed on the claim does not match the place of service detailed in the records.      Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist office visit (99214), the destruction of premalignant lesions (17004), a punch biopsy of skin (11104), and a tangential biopsy of the skin (11102, 11103) provided on April 29, 2021, by an OON provider.  You asked the Plan to pay for a specialist office visit, the destruction of premalignant lesions, a punch biopsy of skin, and a tangential biopsy of the skin. You say that you did not realize and were not told that you needed referrals to see your previous doctors. The Plan denied your request. The Plan says these services were provided by a non-contracted provider. The Plan also says that there is no record of an approved referral being obtained from the member's primary care provider (PCP) prior to services being rendered.    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 a specialist office visit (99214), the destruction of premalignant lesions (17004), a punch biopsy of skin (11104), and a tangential biopsy of the skin (11102, 11103) provided on April 29, 2021, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the neuromonitoring services provided on June 28, 2021.  You asked the Plan to pay for the neuromonitoring services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.  We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we decided that the Plan does not have to pay for the neuromonitoring services provided on June 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under 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 Eliquis.        Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99335) provided on September 9, 2021
by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the out-of-network services were not pre-authorized 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 services at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided
that the Plan does not have to pay for physician services (99335) provided on September 9, 2021 by an out-of-
network (OON) provider.