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

We decided that the Plan does not have to pay for the dentures (D5140), provided on July 30, 2021.
You asked the Plan to pay for the dentures. You say that the service should be covered. The Plan denied your
request. The Plan says this is not a covered service.
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. Specifically, this service is not listed in the Plan's benefit chart. This
means the service is not covered. Therefore, we decided that the Plan does not have to pay for the dentures
(D5140), provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on June 9, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no
documentation of contact in the patient record.

The Plan must follow Medicare rules. Medicare rules say that the CP must attempt to consult with the patient's
physician within a reasonable time after receiving the consent. If the CP's attempts to consult directly with the
physician are not successful, the CP must notify the physician within a reasonable time that he or she is
furnishing services to the patient. Additionally, the CP must document, in the patient's medical record, the date
the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did
not succeed, that date and manner of notification to the physician.

We looked at the file and Medicare rules. The submitted documentation does not show that the CP attempted to
consult with the enrollee's physician. 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
psychotherapy services provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fundus photography with interpretation and report (92250) provided May 25, 2021.
You asked the Plan to pay for the eye exam with photos. You say that you expected your provider to verify your benefits prior to the service being provided. The Plan denied your request. The Plan says this service is not covered under your benefits and your provider submitted documentation showing that you were advised of the out-of-pocket cost for this screening procedure, and you elected to have it performed.
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. Though the Plan offers vision benefits in excess of Medicare coverage, the fundus photography is not among those covered services. Therefore, we decided that the Plan does not have to pay for the fundus photography with interpretation and report (92250) provided May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a monitoring feature/device (A9279) provided March 24,
2021.
You asked the Plan to pay for a monitoring feature/device. You say that you would like reconsideration based
on the medical records provided. The Plan denied your request. The Plan says this code is not valid for
Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code A9279 is not supported for separate payment. Specifically, this code is not separately
paid by Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of a
monitoring feature/device have not been met. Therefore, we decided that the Plan does not have to pay for a
monitoring feature/device (A9279) provided March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) office visit
provided on June 30, 2021.
You asked the Plan to waive the copayment for the PCP office visit. You say that you went for an annual
physical and the charge was incorrectly coded as a regular office visit. The Plan denied your request. The Plan
says you have been 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 $0
copayment for annual physicals. This does not include lab or diagnostic tests, and additional copayments or
coinsurance may apply to additional services provided at your visit.
Your contract with the Plan also clearly says that you must pay a $25 copayment for medical care provided by
a primary care physician.
The record shows that in addition to the physical exam, you were also seen for abdominal pain issues. This
goes beyond the scope of the annual physical and is subject to the copayment. Therefore, you have been asked
to pay a $25 copayment for the PCP office visit. The PCP office visit falls within the Physician/Practitioner
Services, Including Doctor's Office Visits 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 primary care physician (PCP) office visit provided on June 30, 2021.
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 the SNF admission. You say that it is felt that ongoing care is needed in the
SNF setting. The Plan denied your request. The Plan says criteria for SNF care are not 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 SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male with a history
of stroke who has been receiving treatment in an acute rehabilitation facility. Admission to SNF is now
requested. From a nursing perspective, the beneficiary received enteral nutrition and medications. The
beneficiary had stable vital signs, and his lungs were clear. Regarding rehabilitation services, the beneficiary
received physical, occupational, and speech therapy. The beneficiary was at a maximal to total assist level for
functional mobility. The beneficiary required varying assist with daily living activities. He had ongoing
dysphagia.
There are identifiable skilled nursing service needs and identifiable skilled therapy need; however, the enrollee
does not require these services on a daily basis. This beneficiary does not meet severity of illness or intensity of
service criteria for an inpatient basis in a skilled nursing facility 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 admission 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing (SN) services of a registered nurse
(RN) (G0299) and home health care provided in patient's home/residence (Q5001) provided from May 1, 2021,
to May 30, 2021.
You asked the Plan to pay for the direct SN services of a RN and home health care. The Plan denied your
request. The Plan says the Plan did not receive the initial Request for Anticipated Payments (RAP) claim
within 5 calendar days from the start of care.
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day
periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set
at 0 percent at the beginning of every 30-day period.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the direct SN services of a RN and home health care have not been met. Specifically, the record
indicates the RAP was not submitted within 5 days of the from the start of care date, May 1, 2021. Therefore,
we decided that the Plan does not have to pay for the direct skilled nursing (SN) services of a registered nurse
(RN) (G0299) and home health care provided in patient's home/residence (Q5001) provided from May 1, 2021,
to May 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiation therapy, provided on May 28, 2020, through June 11, 2020.
You asked the Plan to waive the copayment for the radiation therapy. You say that the cost share is wrong. The Plan denied your request. The Plan says the cost share 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 outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a 20% coinsurance for the radiation therapy. This 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 the radiation therapy, provided on May 28, 2020, through June 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540, 83550, 83970, 84100) provided on June 9, 2021.

You asked the Plan to pay for laboratory services. You say that you do not have a contractual agreement to include these services in the dialysis rate. The Plan denied your request. The Plan says these services are not separately payable.

The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals for the treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System (PPS) as Part B services and are not paid separately. 

We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of ESRD. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Based on this information, we decided that Medicare rules for coverage of laboratory services have
not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540, 83550, 83970, 84100) provided on June 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing provided on June 21, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
screening test.

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 testing 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 testing
provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care (99220) provided April 9, 2021.

You asked the Plan to pay for the observation care. You say that please review the records, process and pay the claim as both providers should be paid for their services. The Plan denied your request. The Plan says the claim was previously billed by and paid to another provider for this service.

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 99220 is initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history, a comprehensive examination and medical decision making of high complexity.

We find that CPT code 99220 is not supported in the medical record. Specifically, the enrollee was provided physician services while in observation. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital. Based on this information, we decided that Medicare rules for coverage of the observation care have not been met. Therefore, we decided that the Plan does not have to pay for initial observation care (99220) provided April 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can remain in the current acute care location until such time that no further acute level care is needed.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be stable and improving with treatment and should only require short-term additional acute care services that can safely be received at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered soon when treatment has completed.
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kadcyla, Ondansetron, Diphenhydramine and Dexamethasone for the enrollee.

You asked the Plan to pre-approve Kadcyla, Ondansetron, Diphenhydramine and Dexamethasone. You say that these drugs are medically necessary. The Plan denied your request. The Plan says that the requested drugs would be deemed a routine cost covered by the Medicare Administrative Contractor (MAC).

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. 

In this case, you asked the Plan to pre-approve Kadcyla, Ondansetron, Diphenhydramine and Dexamethasone as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Kadcyla, Ondansetron, Diphenhydramine and Dexamethasone for the enrollee.
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 this is medically necessary. The Plan denied your
request. The Plan says intermittent care can be provided utilizing the enrollee's Part B benefits.

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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

You were admitted for surgical repair of a hip fracture after a fall and was transferred to skilled nursing on
12/31/21. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve scalp Integra matrix skin sub (Q4108).

You asked the Plan to pre-approve scalp Integra matrix skin sub. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that this is considered experimental/investigational for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 scalp Integra matrix skin sub. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is an 80-year-old woman with a diagnosis of biopsy-proven squamous cell carcinoma of the occipital scalp. Mohs surgery is planned. The reconstructive surgeon has stated, "There is exposed bone, I will need to use Integra to provide soft tissue framework for skin grafting." The documentation supports that the use of Integra matrix skin substitute is medically reasonable and necessary for the enrollee in this case. This matrix is to provide a scaffold for cellular invasion and capillary growth and provide coverage over exposed bone for this enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of scalp Integra matrix skin sub have been met. Therefore, we decided that the Plan has to pre-approve scalp Integra matrix skin sub (Q4108).

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the inpatient hospital care provided from 
November 7, 2020, through November 11, 2020.

You asked the Plan to waive the cost share for the inpatient hospital care. You say that you would like this 
copayment waived. The Plan denied your request. The Plan says the cost share has processed correctly in this 
case.

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 $225 
copayment for Inpatient Hospital Care. 

You have been asked to pay a $900 copayment for the inpatient hospital care. This care falls within the 
Inpatient Hospital Care 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 cost share for the inpatient 
hospital care provided from November 7, 2020, through November 11, 2020.
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 it is felt that IRF care would be ideal for the enrollee.
The Plan denied your request. The Plan says criteria for this level of care are not 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 enrollee was admitted to the hospital on 1/19/2022 due to arrhythmia found on
pre-operative testing. She underwent incision and drainage of the right knee on 1/21/2022 and knee
replacement revision surgery on 1/24/2022. She is currently weightbearing as tolerated and requires minimal
assistance of two for bed mobility and transfers.
The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not
shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The
enrollee's care needs can be met at a lower level of care.
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.