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 enrollee needs to transition to rehabilitation and the longer he lays in bed the more his strength will decline. The Plan denied your request. The Plan says the guidelines for coverage haven not been met. The Plan says that the enrollee's needs can be met in a less intensive setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for spinal surgery. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PalinGen.
You asked the Plan to pre-approve PalinGen. You say that the enrollee has always had this service. The appellant says that the records provided support the need for PalinGen. 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 PalinGen. Our reviewer says that PalinGen is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic venous hypertension (idiopathic) with ulcer of unspecified lower extremity. The records do not show that the enrollee has tried and failed 30 days of standard wound care based on consecutive weekly wound measurements.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PalinGen have not been met. Therefore, we decided that the Plan does not have to pre-approve PalinGen.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from September 1, 2020, to September 9, 2020.

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 that the DRG was updated in this case.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not substantiated their denial. If the plan has decided to update the DRG from 336 to 337, then they must have had some medical and clinical information to make this decision. The plan has not stated what they are basing the denial on, and the plan has not provided the records that helped them make this decision. Therefore, we decided that the Plan has to pay for inpatient hospital services provided to the enrollee from September 1, 2020, to September 9, 2020.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 27, 2021.
You asked the Plan to pay for the lab 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 lab services have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 4, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network chiropractic care.

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 and chiropractic care requires prior authorization.

The 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 out of network physician services provided to the enrollee on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve hearing aids. You say that you previously received hearings aids from this
provider. You also say you trust this provider and the location is convenient for you. The Plan denied your
request. The Plan says the requested service is available in-network.
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
hearing aids to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme (Q0138).
You asked the Plan to pre-approve Feraheme. You say that Feraheme is medically necessary. The Plan denied your request. The Plan says a trial of Infed or Venofer is required before alternatives can be considered.
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 Feraheme. Our reviewer says that Feraheme is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred medications or any reason they would be unsafe or ineffective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme (Q0138).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 11, 2021.
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 services are not separately payable.
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 11, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the screening breast tomosynthesis rendered on September 30, 2021.
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 that procedure code 77067 is inclusive to code 77063.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan states that code 77067 cannot be paid separately, as it has a National
Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edit with a modifier indicator of 1 with code
77063; however; no active PTP edits exist between these two codes. The Plan has not provided any
documentation to support that the code is not payable as billed. Therefore, we decided that the Plan has to pay
for the screening breast tomosynthesis rendered on September 30, 2021.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete
series x-ray (D0210) provided on September 9, 2021.
You asked the Plan to pay for the dental services. You say that you were told the visit was covered at 100%.
You say that you were reassured more than once that there would be no cost for the visit. You say that you
received a bill for $187. You also say that you feel you should not be responsible for the full amount. The Plan
denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan
says that 1 complete series x-ray is covered every 3 plan years. The Plan also says that the frequency limits
have 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 the services are listed as covered,
the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral
evaluation and complete series x-ray that you received on May 5, 2021. Therefore, we decided that the Plan
does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210)
provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for moderate sedation services (procedure code 99153) provided to the enrollee on July 1, 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 that the place of service was inappropriate for the procedure.

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 99153 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)."

We asked our coder 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 the services at issue in this case were supported by the medical records. Our reviewer found the plan states that an inappropriate place of service was reported for this procedure; however, moderate sedation was required for the approved procedures, and therefore would be covered. Also, moderate sedation would not require a PC/TC modifier. The provider clearly documents "Moderate conscious sedation administered/monitored by IR nurse" which is qualified for services provided.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for moderate sedation services (procedure code 99153) provided to the enrollee on July 1, 2021.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on June 15,
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 claim should be resubmitted with an appropriate ASA code.
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 the denied codes is:
CPT 00752:
Anesthesia for hernia repairs in upper abdomen; lumbar and ventral (incisional) hernias and/or wound
dehiscence
CPT 99100:
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 asked our coder 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 the services at issue in
this case were not supported by the medical records. Our reviewer found that in this case, a review of the
anesthesia report cannot be read, due to poor copy. There is no way to confirm the procedure that anesthesia
services were provided for.
We looked at this coder'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 anesthesia services provided to the enrollee on June 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of any joint of upper extremity (73221) rendered on October 22, 2021.
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI) of any joint of upper extremity. You say that you would like your insurance to cover the balance of $105 for MRI imaging. The Plan denied your request. The Plan says you were charged the correct cost sharing 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 $105 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).
You have been asked to pay a $105 copayment for a magnetic resonance imaging (MRI)of any joint of upper extremity. A magnetic resonance imaging (MRI)of any joint of upper extremity 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 a magnetic resonance imaging (MRI) of any joint of upper extremity (73221) rendered on October 22, 2021.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve use of Evenity.
You asked the Plan to pre-approve Evenity. You say that considering the enrollee has endocrine and low
testosterone scores, the enrollee would best be treated with Evenity instead of Prolia or zoledronic acid. The
Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the
Plan requires a trial of Prolia or Reclast before it will approve Evenity.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. Medicare covers Part B medications when they are reasonable and necessary but allows health plans
to implement step therapy criteria.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Evidence of Coverage submitted by the Plan does not indicate that step
therapy criteria have bene implemented that are applicable to Evenity. Although the Plan did submit a
Medicare Part B preferred drug list, the record does not support that the enrollee's is contractually obligated to
try a preferred drug such as Prolia or Reclast before using Evenity. Therefore, the Plan has not shown that its
decision to deny authorization for Evenity is correct or justified according to Medicare rules or the enrollee's
contract with the Plan. Therefore, we decided that the Plan has to pre-approve use of Evenity.
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: 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 requested admission to a SNF is medically
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet
criteria.

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
service is medically necessary. Our physician reviewer found daily skilled services are required. The enrollee is
not able to ambulate household distances and requires moderate assistance for mobility which is reported to be
a decline from her baseline. Despite the enrollee's dementia, therapy notes document she is appropriate and
cooperative with therapy and has already made small improvements in function with therapy in the hospital.
Available records appear to indicate that further improvement in function can be expected in a reasonable time
frame as required by Medicare criteria for skilled therapy 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a full set of dental x-rays provided by a participating
provider on October 13, 2021.

You asked the Plan to pay for dental x-rays. You say that this is a new dentist. You say that they needed a full
set of x-rays. The Plan denied your request. The Plan says the benefit limit for dental x-rays has already been
exhausted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental x-rays
once every five years.

We looked at the file and Medicare rules. Evidence was provided to show that these services were provided on
June 24, 2021, and June 30, 2021. Based on this information, we decided that the Plan's rules for coverage of
dental x-rays have already been met. Therefore, we decided that the Plan does not have to pay for a full set of
dental x-rays provided by a participating provider on October 13, 2021.