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 without this care, the enrollee would be unable to return to the current living situation safely. The Plan denied your request. The Plan says an intensive rehabilitation program 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 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 a concussion and bilateral nasal fractures after a fall. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that this request is medically reasonable and necessary.
The Plan denied your request. The Plan says rules for SNF care have not been met.
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 daily
skilled services are not necessary. Our physician reviewer found you are a 78 year old female resident of a
group home with a past medical history of hypertension, hyperlipidemia and hypothyroidism who presented to
the acute hospital on September 11, 2021, with altered mental status, acute kidney injury, a urinary tract
infection and lower extremity cellulitis. While you do require skilled therapy services, there is no
documentation that you require skilled nursing service. However, based on the medical records provided daily
skilled services are not required for your medical condition. You do not require the services on an inpatient
basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear
appropriate in this case.
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 not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 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 submitted records do not support the billing of code 15002.
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 15002 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children. 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 these services. Our reviewer says that the submitted records do not support the billing of code 15002. Our reviewer found the report documents open wound debridement and not preparation of, or creation of, recipient site by excision of open wounds. There is a more appropriate code to report for wound debridement. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on March 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from March 10, 2020 to March 17, 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 services were not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 services were not medically necessary. Our physician reviewer found there is no submitted documentation to support that there had been measurements to prior assessments for the dates of service at issue. The services were not documented appropriately; therefore, the records do not support that the services were reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from March 10, 2020 to March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on May 17, 2021.
You asked the Plan to pay for an eye refraction. You say that the provider is an in-network provider. The Plan denied your request. The Plan says an eye refraction is not a covered benefit since it was a medical vision check.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when it is obtained through one of the Plan's routine vision service vendors. We looked at the file and the Plan's rules. An eye refraction is not covered if performed by a provider that is not part of the Plan's routine vision service vendors. The provider at issue is not one of the Plan's routine vision service vendors. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided April 6,
2021.

You asked the Plan to pay for the periodontal maintenance. You say that it used to cost a little and now it costs
a lot for the periodontal cleanings. The Plan denied your request. The Plan says this service is 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
periodontal maintenance (D4910) provided April 6, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the mental health services provided on April 5, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says that there is no referring provider listed on the claim.

The Plan must follow Medicare rules. Medicare rules say that if the patient consents, you must attempt to consult their attending or primary care physician about provided services. 

We looked at the file and Medicare rules. In this case, there is a referring provider listed on the claim. Therefore, the Plan's denial cannot be substantiated. 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 the mental health services provided on April 5, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the stress test rendered on March 31, 2021.

You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the deductible was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is $250 yearly deductible which applies to your covered medical services.

The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $250
yearly deductible which applies to your covered medical services. This cost sharing is a contractual obligation
that had not been met at the time these services were received on March 31, 2021. Therefore, we decided that
the Plan does not have to waive the deductible for the stress test rendered on March 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the double contrast x-ray of esophagus (CPT code 74221)
provided to the enrollee on April 20, 2021.
You asked the Plan to pay for the x-ray. You say that the claim should be paid. The Plan denied your request.
The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the x-ray have not been met. Our records indicate a National
Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 74221 and 74230.
This PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this
PTP code pair. Therefore, we decided that the Plan does not have to pay for the double contrast x-ray of
esophagus (CPT code 74221) provided to the enrollee on April 20, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care provided on April 23, 2021.
You asked the Plan to waive the copayment for the emergency care. You say that you only wanted to go to urgent care where you only have to pay $10 copay for out-of-network provider but was not able to because the urgent care which is the nearest urgent care from your home does not accept the Plan. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received emergency care on April 23, 2021. You were asked to pay a $70 copayment for the emergency care. Your 2021 EOC states that enrollees must pay a $70 copayment for each
Medicare-covered emergency room visit. 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 emergency care provided on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device (E0730) rendered by the out-of-network (OON) provider on November 9, 2020.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device (E0730) rendered by the out-of-network (OON) provider on November 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary for treatment of psoriasis.
The Plan denied your request. The Plan says the doctor must confirm screening for the presence of
tuberculosis.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found there is no
documentation that confirms that the enrollee has been screened for tuberculosis and will be receiving ongoing
monitoring. There is no confirmation that the enrollee is a candidate for systemic therapy or phototherapy. The
review has determined that the documentation does not support that the Ilumya is medically reasonable, safe,
effective, and necessary for the 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 the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Ilumya for the enrollee
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the magnetic resonance imaging (MRI),
echocardiography, and the peripheral vascular test provided from March 8, 2021, through May 24, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to
the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay 20% of the cost of diagnostic tests and procedures.
The enrollee has been asked to pay $215.16 for the diagnostic tests provided. This includes the Plan allowed
amount of $366.29 x 20% = $73.26 for the MRI, the Plan allowed amount of $480.49 x 20% = $96.10 for the
echocardiography, and the Plan allowed amount of $228.98 x 20% = $45.80 for the peripheral vascular test
provided. This means that the enrollee has been asked to pay the correct amount based on the contract with the
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.
Therefore, we decided that the Plan does not have to waive the coinsurance for the magnetic resonance imaging
(MRI), echocardiography, and the peripheral vascular test provided from March 8, 2021, through May 24,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation (RFA) services.
You asked the Plan to pre-approve the lumbar facet joint RFA services. You say that the enrollee has had two positive diagnostic facet injections with 85% pain relief both times. You say that the enrollee is in severe pain. The Plan denied your request. The Plan says the clinical information provided does not show that the criterion for coverage has been met.
The Plan follows Medicare rules. Medicare rules say that RFA services are covered for certain indications. Medicare rules also say that only one or two levels of RFA services are allowed per session per spine region, unless there is a unique circumstance of medical necessity is sufficiently documented. 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 lumbar facet joint RFA services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the initial and diagnostic medical branch blocks only provided 55% relief. Additionally, the provider is requesting to perform the RFA procedure to 3 levels. However, the documentation provided does not show that there is a unique circumstance that makes a third level medically reasonable and necessary. 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 lumbar facet joint RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation (RFA) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the thoracic spine for the enrolle.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical indication for immediate advanced imaging.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the neurological exam revealed no absent or diminished reflexes, and no weakness. There is no history of trauma or malignancy. The DEXA scan is pending to screen for osteoporosis. The plain films, aside from degenerative changes of the cervical spine, are unremarkable. Thus, there is no red flag to mandate immediate MRI exam of either the cervical or thoracic spine prior to a monitored 6 week trial of physical therapy.
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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the thoracic spine for the enrolle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a vitrectomy chair.
You asked the Plan to pay for the chair. You say that this is a lot of money for you right now. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a vitrectomy chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Biocept profile rendered on March 29, 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 was 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 pay for these services. Our reviewer says that the testing was not medically necessary.
Our physician reviewer found the enrollee has adenocarcinoma of the lung. A computed tomography (CT) scan of the chest on March 22, 2021 showed the lung mass had increased in size. It has not been clearly established that Biocept non-small cell lung cancer profile testing impacts outcomes of patients with non-small cell lung cancer (NSCLC). The testing was not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Biocept profile rendered on March 29, 2021.