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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from
April 24, 2021, to May 23, 2021.
You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare
Act. The Plan denied your request. The Plan says the enrollee had returned to their physical baseline. The Plan
says that the enrollee can continue receiving therapy at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that the
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill,
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing
and/or skilled therapy on an inpatient basis in a SNF 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 the SNF services have not been met. Specifically, the file does not show that the
enrollee required daily skilled services. Therefore, we decided that the Plan does not have to pay for the skilled
nursing facility (SNF) services provided from April 24, 2021, to May 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the physician services and Part B drugs rendered on January 27, 2021 to January 28, 2021.
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the cost sharing was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for chemotherapy drugs and all other drugs covered under Medicare Part B and a $35 copayment for physician specialist services.
Review of the file shows that you received Part B drug services on January 27, 2021 and January 28, 2021. You have been asked to pay a 20% coinsurance for these services, for a total of $103.39. These services fall within the chemotherapy drugs and all other drugs covered under Medicare Part B benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received specialist services on January 28, 2021. You have been asked to pay a $35 copayment for these services. These services fall within the physician specialist services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The total amount you have been asked to pay for these services is $138.39. 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 cost sharing for the physician services and Part B drugs rendered on January 27, 2021 to January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81407, 81408) provided January 14, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services billed are not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing / panels. We looked at the file and Medicare rules. The services at issue are not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81407, 81408) provided January 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve these services. You say that you have lymphedema from chemotherapy. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be covered. The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the transthoracic echocardiography (93306) provided on May 6, 2021.
You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 copayment for in-network Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility. Additionally, the yearly deductible is $500. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical services. You have been asked to pay $505.27 which is the Medicare allowable amount for this service. This amount includes a deductible applied of $376.41 as you have previously met $123.59 of the Plan's $500 deductible for this calendar year. Additionally, you have been asked to pay a copayment of $128.86 for the in-network Medicare-covered radiological diagnostic service provided which is less than the applicable copayment. 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 adjust the cost share for the transthoracic echocardiography (93306) provided on
May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on April 2, 2021.
You asked the Plan to waive the copayment for the laboratory services. You say that your plan says a $0 copayment when done at qualified doctor office or hospital. 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 the laboratory services on April 2, 2021, at a medical center. The services were not performed at your physician's office or independent lab location. Therefore, you are asked to pay a $25 copayment for the laboratory services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services provided on April 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued services in a skilled nursing facility (SNF).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says continued coverage is no longer medically necessary.
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 the services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no documented skilled nursing
or skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to
prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a
practical matter, can be provided at a lower level of care (ex. home, AL, LTC).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued services in a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication of frequent adjustment of the insulin regimen.
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is adjustding insulin doses according to blood glucose levels. Hence, the criteria is not met. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta 32MG ER Suspension, left knee.
You asked the Plan to pre-approve Zilretta 32MG ER Suspension, left knee. You say that the first injection worked so great it literally gave you your life back. The Plan denied your request. The Plan says that Zilretta injections are not approved by the FDA for repeat use and can only be used once per knee per lifetime.
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 Zilretta 32MG ER Suspension, left knee. Our reviewer says that the documentation supports that Zilretta is medically reasonable and necessary for the patient and is safe and effective for the patient. Our physician reviewer found based on the Label, it does not preclude use of the drug more than one time. In addition, based on the regulation 50.4.1 - Approved Use of Drug, Drugs or biologicals approved for marketing by the Food and Drug Administration (FDA) are considered safe and effective for purposes of this requirement when used for indications specified on the labeling. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta 32MG ER Suspension, left knee have been met. Therefore, we decided that the Plan has to pre-approve Zilretta 32MG ER Suspension, left knee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 7, 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 procedure code 70450 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 7, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve dilation of the eustachian tube.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that this service is considered experimental and investigational.
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 requested services. Our physician reviewer found that you have been diagnosed with bilateral eustachian tube dysfunction. You have constant cracking and popping of your ears. You also feel like your ears are under water with pressure and fluid behind them. You have bilateral mild to moderate mixed hearing loss, type A tympanograms, and your ear exam was normal. The Academy of Otolaryngology published a consensus statement of eustachian tube dysfunction (ETD) and dilation. They state that balloon dilation is appropriate in patients with obstructive ETD who have failed medical therapy. This patient has been treated for allergies and sinus issues. The placement of pressure equalizer tubes is not a mandatory prerequisite for dilation of the ET. You have been diagnosed with ET dysfunction. You have the classic symptoms of this condition. You have not improved with medical management. Therefore, the requested dilation services are considered 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 requested services have not been met. Therefore, we decided that the Plan has to pre-approve dilation of the eustachian tube.
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 physician services (99213) provided on November 3, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says there were network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided
that the Plan does not have to pay for physician services (99213) provided on November 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound (76770) provided May 5,
2021.
You asked the Plan to waive the copayment for the ultrasound. You say that the copayment should be waived.
The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 $40
copay for x-ray services.
You have been asked to pay a $40 copay for the ultrasound. The ultrasound falls within the x-ray services
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 (76770) provided
May 5, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (43239) and a colonoscopy (45380) performed on February 1, 2021.
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy and a colonoscopy. You say that the Plan should pay the bill at issue. The Plan denied your request. The Plan says the correct copayment was applied.
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 $425 copayment for each Medicare-covered outpatient surgery at an ambulatory surgical center or a hospital outpatient facility.
You have been asked to pay a $425 copayment for an esophagogastroduodenoscopy and a colonoscopy. An esophagogastroduodenoscopy and a colonoscopy fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (43239) and a colonoscopy (45380) performed on February 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (47420) provided on February 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.
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 47420 is "Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without cholecystotomy; without transduodenal sphincterotomy or sphincteroplasty". 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 use of code 47420 is not supported by the records provided. Our reviewer found that the operative report documents a "biliary Fogarty was passed down through the cystic duct into the ampulla without resistance. This allowed us to carefully examine the area of the ampulla, that showed no evidence of a mass or thickening. The balloon was then withdrawn, and the systic duct was ligated with 2-0, silk tie". The records do not include documentation of drainage or removal of calculus, which is included in the description for this procedure. 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 the services (47420) provided on February 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after September 19, 2021.
You asked the Plan to pre-approve the continuation of SNF care. You say that you need SNF care. 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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 78-year-old female with a past medical history of diabetes and hypertension who presented to the acute hospital on August 17, 2021, with malignant neoplasm of the urinary bladder. While you do require skilled therapy services, you do not require skilled nursing services. In addition, based on the medical records provided daily skilled services are not required. In conclusion, you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or 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 the continuation of skilled nursing facility (SNF) care after September 19, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist services provided from
January 14, 2020, to November 13, 2020.
You asked the Plan to waive the copayments for the specialist services. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received services provided by a specialist on the dates of service at issue in this
appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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 $50
copayment for services obtained from a specialist.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services
obtained by a specialist from January 14, 2020, to November 13, 2020. You have been asked to pay an $11.34
copayment for each specialist visit provided from January 14, 2020, to March 10, 2020, and an $11.41
copayment for each specialist visit provided from April 2020 to November 13, 2020, which is less than the
contracted $50 copayment amount. The specialist services fall within the Physician/Practitioner Services
benefit category. This means that you have been asked to pay the correct amounts 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 copayments for the specialist services provided
from January 14, 2020, to November 13, 2020.