Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you an additional $80 for ophthalmological services, medical examination and evaluation provided on August 11, 2021.

You asked the Plan to reimburse you an additional $80 for ophthalmological services, medical examination and evaluation. You say that that the Plan states you are entitled to a routine eye exam (1 every year) and you pay nothing for this exam. The Plan denied your request. The Plan says that the claim processed according to the out-of-network fee schedule.

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. Specifically, the Plan has not submitted the Explanation of Benefits (EOB) to us as we requested. The Plan has not provided the rule within the EOC to support why only $35 was reimbursed. Per the Plan's EOC under the benefit category of Vision Care it does state you must use the Plan's vision provider to receive the benefit; however, the EOC does not state the benefit amount that is covered when using a provider that is not part of the Plan's vision network. Therefore, we decided that the Plan has to reimburse you an additional $80 for ophthalmological services, medical examination and evaluation provided on August 11, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 20, 2019 to November 30, 2019.

You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the documentation shows that the enrollee had an episode of home health care with a last billed date of service of August 27, 2019. The start of this episode was on October 20, 2019. There was no 60 day gap in home health services. This means the home health billing criteria has not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 20, 2019 to November 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are not having an inpatient procedure.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. There is no documentation that your necessary hospital care would span two midnights.

Provided records do not document medical necessity of inpatient care for the requested procedure, as opposed to performing the procedure as an outpatient. Our physician reviewer found that your condition does not meet criteria for coverage for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6241) and retainer crowns (D6751) provided on September 23, 2021.

You asked the Plan to pay for the pontic and retainer crowns. You say that your dentist is out-of-network, and you believe this claim should not have been totally denied. You also say that this was a necessary procedure and was not a cosmetic procedure. The Plan denied your request. The Plan says these services are not covered benefits under your 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 pontic (D6241) and retainer crowns (D6751) provided on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the filter holder and integrated filter housing coded A7509
provided on June 1, 2021.
You asked the Plan to pay for the filter holder and integrated filter housing. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not
supported by the documentation.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file
shows that the documentation submitted did not include an itemized shipping/billing invoice to indicate the
specific supplies or proof of delivery. The record shows that the Plan made several attempts to obtain the
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the
filter holder and integrated filter housing coded A7509 provided on June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Exemestane tablet.
You asked the Plan to pre-approve Exemestane. You say that the requested treatment is a medical necessity for
the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered oral anti-
cancer drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B because the requested drug does not have the same active ingredients as anti-cancer
chemotherapeutic agents which would be covered if they were not self-administered and they were furnished
incident to a physician's service. Therefore, we decided that the Plan does not have to pre-approve treatment
with Exemestane tablet.
Benefits for Exemestane 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, chest (71045) provided September 7,
2021.
You asked the Plan to pay for the diagnostic service. You say that you billed CPT 71045-26 only once for this
date. You are requesting reconsideration of the determination and issue payment. The Plan denied your request.
The Plan says payment for this claim/service may have been provided in a previous payment.
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 71101-26, LT. 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 radiologic examination, chest (71045) provided September 7,
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 records provided support the need for
LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute
care and is currently unstable for transfer to an LTACH.
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 short-term acute care hospital can provide for all of the patient's present inpatient
care needs and the enrollee is receiving an appropriate level of care in the present setting. Given the latest
records report concern for a new hospital-acquired pneumonia with fever, leukocytosis and worsening
pulmonary infiltrates, the enrollee does not appear to be stable for transfer out of the short-term acute care
setting. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer
to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled
nursing facility.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64629 and
64628), for the enrollee.
You asked the Plan to pre-approve the intracept procedure. You say that the services are medically necessary.
The Plan denied your request. The Plan says medical studies have not proven that the service(s) or procedure(s)
is helpful for treatment of the enrollee's health problem.
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 the 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 intracept procedure is experimental. More research is needed to show safety and
efficacy.
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 intracept procedure have not been met.
Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64629
and 64628), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron tablet, 4 mg.

You asked the Plan to pre-approve Ondansetron. You say that the enrollee experiences nausea as a result of the pain medication they are on. You also say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered drug.

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. Additionally, the file shows that the enrollee is not currently receiving chemotherapy. Therefore, we decided that the Plan does not have to pre-approve Ondansetron tablet, 4 mg.
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 would benefit from IRF care to optimize her level of functioning prior to returning home. You say that the enrollee's chance to return home and maintain living at home will be significantly reduced if her opportunity to participate in an acute rehabilitation program is denied. You say that the enrollee meets all applicable Medicare criteria for admission to an IRF. The Plan denied your request. The Plan says the enrollee could receive care in another setting. The Plan says that the guidelines for IRF care have not been met.

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 kyphoplasty of thoracic compression fractures after a fall. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 26, 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 covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the revascularization procedure you had at an outpatient hospital facility on July 26, 2021.

You asked the Plan to waive the copayment for the revascularization procedure. You say that you had this same procedure in June and didn't have to pay a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that at the time this claim was processed, you only had $164.42 remaining on your maximum out-of-pocket amount for the year, so your copayment obligation is limited to that 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 $250 copayment for outpatient procedures and services.

You have been asked to pay a $250 copayment for the revascularization procedure. The revascularization procedure falls within the outpatient procedures and services benefit category. This copayment applies regardless of what you may have paid in the past for similar procedures. 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 the revascularization procedure you had at an outpatient hospital facility on July 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on July 22, 2021 to July
23, 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 covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services
were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion
therapy rendered on July 22, 2021 to July 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services (62320) provided on September 13, 2021.

You asked the Plan to pay for the injection services. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says despite multiple outreaches, required documentation is missing.

The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. In this case, despite the Plan's request no medical records were provided to corroborate the services as billed. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services (62320) provided on September 13, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for the magnetic resonance imaging (MRI) of the brain (70551) provided on January 21, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment The Plan denied your request. The Plan says that the copayment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. 

The Plan says you must pay a $75 copayment for the Medicare-covered diagnostic radiology service provided. According to the medical records provided in this case you were admitted as an inpatient into the hospital on this day. There is an applicable copayment that would apply to each inpatient hospital admission. However, the radiology services provided during this inpatient stay would be covered with no additional copayment. Therefore, we decided that the Plan has to waive the copayment for the magnetic resonance imaging (MRI) of the brain (70551) provided on January 21, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 10, 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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 15, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says lines 1 and 3 of the claim cannot be paid for.
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 83520 is "Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified." 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 the physician order is illegible, and the test ordered cannot be read. However, the result does not support more than nine units, so eleven units cannot be verified.
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 laboratory services provided to the enrollee on June 15, 2021.