Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not require skilled services 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 services. Our physician reviewer found that you do not have documented skilled nursing or therapy needs. You are not shown to have an acute decline in function, for which daily skilled services are required to establish a maintenance program or to prevent deterioration of your condition.  

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for service between 10:00PM and 8:00AM (99053) provided on March 25, 2021.  You asked the Plan to pay for overnight medical service. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code is always bundled for payment and is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that code 99053 is always bundled for payment and if it is covered the payment for it is subsumed by the payment for services to which it is incident.   We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of overnight medical service have not been met. Therefore, we decided that the Plan does not have to pay for service between 10:00PM and 8:00AM (99053) provided on March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab work provided by an out-of-network provider on June 17, 2021.  

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services were not emergent in nature.  

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 lab work provided by an out-of-network provider on June 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 71045) provided to the enrollee on August 5, 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 an appropriate modifier was not billed in this case.  

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 71045 is a column II code to column I code 77001. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (procedure code 71045) provided to the enrollee on August 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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity setting.  

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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311).  

You asked the Plan to pre-approve an expandable controller. You say that this device is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  

The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria listed 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 an expandable controller. Our reviewer says that the requested expandable controller is not medically reasonable and necessary according to the Medicare rules. Our physician reviewer found that the patient does not require non-proportional input devices (e.g., sip and puff, head array, etc.). Furthermore, the patient does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The patient has 3 power options of tilt, recline, and power elevating leg rests but the patient does not need to control the power options through a joystick. The patient's upper extremity strength and function support that the patient can control any power options through their own switches. 

 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve routine transportation using a stretcher.  

You asked the Plan to pre-approve routine transportation using a stretcher. You say that you are unable to walk and need transportation using a stretcher to get to your medical appointment. The Plan denied your request. The Plan says the service at issue is not a covered benefit.  

The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule.   

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation using a stretcher have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation using a stretcher.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Enhertu.  

You asked the Plan to pre-approve Enhertu. The Plan denied your request. The Plan says it does not meet medically accepted indications.  

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 Enhertu. Our physician reviewer found that the enrollee has locally recurrent breast cancer. As this is not an unresctable disease, there is no role for Enhertu in the adjuvant or neoadjuvant setting. It is approvable for unresectable recurrence or metastasis only after prior anti her 2 neu therapy. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.     

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Enhertu have not been met. Therefore, we decided that the Plan does not have to pre-approve Enhertu.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a preventive evaluation received on September 24, 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 the benefit maximum has been reached.  

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months.   

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for a preventive evaluation received on September 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Intracept procedure.  You asked the Plan to pre-approve Intracept procedure. 

You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. the Intracept procedure is experimental. More research is needed to show safety and efficacy of the procedure. Therefore, the enrollee does not meet criteria for the requested 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

 You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria. 

 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.   
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on January 18, 2021.  

You asked the Plan to pay for the transportation services. You say that the transportation services were medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for immunization services provided to the enrollee on August 9, 2021.  

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit. 

 In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules.  

 Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.        

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be unstable and critically ill and requires additional acute care services that can be safely completed at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Completion of treatment at the current facility is recommended and transfer may be considered when the enrollee is more stable.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 10, 2021.  

You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $115 copayment for ultrasounds.   

You have been asked to pay the allowed amount of $103.43, which is less than the $115 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an ultrasound provided on August 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound study provided on August 12, 2021.  You asked the Plan to waive the copayment for an ultrasound study. You say that the ultrasound study was necessary in order to determine what was causing inflammation and to rule out a blood clot. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $115 copayment for ultrasounds.   You have been asked to pay the allowed amount of $103.43, which is less than the $115 copayment for an ultrasound study. An ultrasound study falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an ultrasound study provided on August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from October 25, 2020 to November 2, 2020.  

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the billing of diagnosis code A41.81.  

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 diagnosis code A41.81 (sepsis due to enterococcus). 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 these services. Our reviewer says that the submitted records do not support the billing of diagnosis code A41.81. Our physician reviewer found the submitted records support an admission for further evaluation and treatment of pneumonia in a patient with a medical history including hypertension and chronic kidney disease. While sepsis was documented in the history and physical, progress notes, and discharge summary; other provider documentation was unclear and incomplete regarding this condition. Subsequent documentation consistently recorded the patient as hemodynamically stable, with normal lactate levels and a Glasgow coma score (GCS) of 15 with normal mentation. Additionally, while the hospital included a serum glucose of 121 mg/dL, this would not be considered evidence reflective of organ dysfunction that is life threatening due to infection. The records do not support the billing of diagnosis code A41.81.   

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 rendered from October 25, 2020 to November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain - minor procedure (D9110) and intraoral - periapical first radiographic image (D0220) provided July 7, 2021.  

You asked the Plan to pay for the emergency treatment of dental pain and periapical x-rays. You say that there is no significant difference between types of x-rays, and you were not told which types would be covered. The Plan denied your request. The Plan says these services are not covered under your benefits.  

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 palliative (emergency) treatment of dental pain - minor procedure (D9110) and intraoral - periapical first radiographic image (D0220) provided July 7, 2021. 
 
 Your complaint about which services are covered under your benefits and specifically the distinction between different types of x-rays 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.