Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Critical Care services (99291) provided March 1, 2021
You asked the Plan to pay for the Critical Care services. You say that the services are medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 99291 is critical care visit of 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not detail how much time was spent on this service. Based on this information, we decided that Medicare rules for coverage of the Critical Care services have not been met. Therefore,
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you cannot walk without substantial pain unless you are wearing orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says Orthovisc is considered experimental, investigational, or unproven for any other use other than for pian regarding the knee.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Orthovisc. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found you are a 73-year-old who has osteoarthritis of the left shoulder. This would be an experimental/ investigational use of the medication. It is only approved for knee osteoarthritis. Therefore, the request is deemed not medically reasonable or 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from March 8, 2021, to March 11, 2021.
You asked the Plan to pay for inpatient stay. You say that the enrollee's hospice was revoked on March 7, 2021 and did not start again until March 12, 2021. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee revoked hospice on March 7, 2021, therefore the Place is not responsible for coverage until the first day of the following month.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on March 7, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from March 8, 2021, to March 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on April 1, 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 codes 27486, 27488, and 11044 are 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 27486 is revision of total knee arthroplasty, with or without allograft; 1 component. The definition of code 27488 is removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee. The definition of code 11044 is debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less.

We find that procedure codes 27486, 27488, and 11044 are not supported in the medical record. Specifically, there is no documentation of revision of a total knee arthroplasty with or without allograft to support code 27486. There is no documentation of removal of prosthesis to support code 27488. There is no documentation of debridment of bone for the first 20sq cm or less to support code 11044. 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 April 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on January 13, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on January 13, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 23, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an assisted living facility setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have deformed feet including amputation of toes. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited (problem-focused) oral evaluation (D0140) and intraoral x-ray (D0220) provided on May 13, 2021.

You asked the Plan to pay for the evaluation and x-ray. You say that have a limited income and feel that your benefits, which you pay extra for, cover very little. The Plan denied your request. The Plan says these services are not covered by the additional optional preventative dental 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. The Plan's optional preventative dental benefits can cover routine exams, dental cleanings, bitewing x-rays and full mouth and/or panoramic x-rays.

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 a limited (problem-focused) oral evaluation (D0140) and intraoral x-ray (D0220) provided on May 13, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT) for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that the treatment plan clearly identified stereotactic body radiation therapy (SBRT) as the treatment approach.
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 the therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found intensity modulated radiation therapy (IMRT) is a technique used to improve the dose conformality. In general, IMRT is not an experimental technique, but rather a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the dose to normal structures. IMRT reflects the planning while stereotactic body radiation therapy (SBRT) reflects the treatment. Thus, IMRT planning and SBRT delivery (5 or few fractions) can be billed as a standard of care approach. 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 therapy have been met. Therefore, we decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided March 31, 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 documentation does not support the billed services.
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 G0482 is not supported in the medical record. Specifically, the place of service on the claim form (81, lab) does not match the place of service detailed in the records (11, office setting). 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 (G0482) provided March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0156) provided October 2, 2020 to October 17, 2020.
You asked the Plan to pay for home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 G0157 is not supported in the medical record. Specifically, the documentation does not show how much time was spent on this service.
Additionally, the provider is not enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0156) provided October 2, 2020 to October 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 12, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 12, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.

You asked the Plan to pre-approve Aduhelm. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the requested use of this drug is experimental.

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 Aduhelm. Our reviewer says that Aduhelm is FDA-approved for the treatment of Alzheimer's disease in patients with mild cognitive impairment or mild dementia stage of disease. The documentation is insufficient to support a diagnosis of Alzheimer's disease in this enrollee. The requested use of Aduhelm is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal Our physician reviewer found there is no documentation of a Mini-Mental State Examination (MMSE) in this case. The results of recent Magnetic Resonance Imaging are not available in this case. It has not been shown that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate alternatives 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested drug is intended for patient self-administration.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick for the
enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this does not meet the criteria.

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 altered mental status, urinary tract infection and sepsis. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted molecular pathology (81479) and
methyenetetrahydrofolate reductase (MTHFR) gene analysis (81291) provided May 25, 2021.

You asked the Plan to pay for the laboratory services. You say that you do not even know what the services
were that you are being billed for. You disagree with the charges. You did get lab services done but you usually
have your labs done through another provider. The Plan denied your request. The Plan says the correct cost
share was applied per the Evidence of Coverage. Claims billed with the GY modifier is not covered by
Medicare.

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 20% coinsurance for genetic testing. 

You have been asked to pay $1313.07 ($13.07 coinsurance and $1300 non-covered service) for the laboratory services. Procedure code 81479 was billed with the GY modifier. Medicare rules say that claims billed with the GY modifier is not covered by Medicare.The laboratory services fall 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 pay for unlisted molecular pathology (81479) and methyenetetrahydrofolate reductase (MTHFR) gene analysis (81291) provided May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your podiatrist advised an orthotic is needed. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infusion services provided from January 14, 2021 to January 30, 2021.

You asked the Plan to waive the coinsurance for the infusion 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 infusion services on the dates of service at issue in this appeal. The Plan says that the correct coinsurance has 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 20% coinsurance for Medicare Part B prescription drugs. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received infusion services from January 14, 2021 to January 30, 2021. You have been asked to pay a 20% coinsurance for each visit for infusion services. The infusion services fall within the Medicare Part B prescription drugs 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 coinsurance for the infusion services provided from January 14, 2021 to January 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided May 11, 2021 to May 14, 2021.
You asked the Plan to waive the copayment for the inpatient services. You say that you were told by the discharge nurse that there would only be a $325 copay. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage
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 $325 per day for days 1-5 for Inpatient hospital care. You have been asked to pay $975 ($325 x 3 days) for the inpatient services. The inpatient services fall 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 copayment for the inpatient hospital services provided May 11, 2021 to May 14, 2021.