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

We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on February
13, 2020.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says the records show there is no indication of signs nor symptoms of cancer or an indication
in the medical records the treating physician requested cancer testing.
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 the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee does not have any symptoms nor a diagnosis that would be identified or modified by the testing. The review has determined that the services at issue in this case were 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing services provided to the enrollee on February 13, 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 the enrollee's clinical condition meets the full IRF criteria. You say that the enrollee's ability to remain in the community setting will be affected, averting unplanned admissions. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive the care needed in another setting.
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 non-surgical management of pelvic fractures after a motor vehicle accident. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from April 5, 2021, to April 8, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $350 copayment per day for days 1-5 for inpatient hospital care. Records show that you were in the hospital for three days. You have been asked to pay a $350 copayment per day for the inpatient hospital 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 inpatient hospital services you received from April 5, 2021, to April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an optometrist visit for a diabetic exam.
You asked the Plan to pre-approve an optometrist visit for a diabetic exam. The Plan denied your request. The Plan says the member's contract requires use of in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan. No network gap exists.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an optometrist visit for a diabetic exam.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tirosint.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tirosint.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from December 26, 2019 to January 4, 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 submitted records do not support the billing of DRG 177 and diagnosis code J15.0.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 

In this case, you billed the inpatient services provided with DRG 177 and diagnosis code J15.0 (bacterial pneumonia, not elsewhere classified). 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 submitted records do not support the billing of DRG 177 and diagnosis code J15.0. Our physician reviewer found the enrollee with a history of stage IV lung cancer was chiefly admitted due to narrow complex tachycardia and atrial fibrillation. The emergency department (ED) documents in the clinical impression the atrial fibrillation with rapid ventricular response (RVR), lung cancer, and dehydration. The admit order states the reason for the admission is the atrial fibrillation with RVR. The enrollee was admitted due to narrow complex tachycardia and atrial fibrillation. Pneumonia was diagnosed after admission; therefore, pneumonia meets the definition of a secondary diagnosis. The records do not support the billing of DRG 177 and diagnosis code J15.0. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from December 26, 2019 to January 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the computerized ophthalmic diagnostic imaging exam (code 92134) you had on April 8, 2021, and the established patient comprehensive eye exam (code 92004) you had on April 16, 2021.
You asked the Plan to waive the copayments for the imaging exam service and the eye exam. You say that you are being charged twice for one session. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan said that for the April 8, 2021 date of service, the allowed amount for the service ($18.37) is less than your copayment obligation, so you are responsible for the full allowed 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 $20 copayment for vision exams or visits.
The records show that you received these two services on two different days, so separate copayments can apply. There is no requirement that providers bill all services on the same day so that you only get one copayment. You have been asked to pay a $20 copayment for the imaging exam service and a $20 copayment for the eye exam. 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 copayments for the computerized ophthalmic diagnostic imaging exam (code 92134) you had on April 8, 2021, and the established patient comprehensive eye exam (code 92004) you had on April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 4, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is 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 the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found this test is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. This testing is considered screening. The review has determined that the enrollee does not meet the criteria for this request. 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 pay for laboratory services provided to the enrollee on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pulmonary office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the pulmonary office visit. You say that you are looking for a second opinion. The Plan denied your request. The Plan says the provider is out-of-network
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the pulmonary office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy 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 this is not a covered benefit for mesothelioma.
The Plan must follow Medicare rules. The rules say that tumor treatment field therapy is only covered for treatment of newly diagnosed glioblastoma. Mesothelioma is not a covered indication for the requested therapy. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from February 17, 2021, to March 11, 2021.
You asked the Plan to pay for these chiropractic services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says these services are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from February 17, 2021, to March 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four additional home health nursing visits for occupational and speech therapy.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says only seven visits can be approved.
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 pre-approve the additional visits. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that skilled therapy services are required for the four unapproved additional requested visits. The provided records do not document why the already approved therapy visits are inadequate to treat your condition. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four additional home health nursing visits for occupational and speech therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Group 3 power wheelchair upgraded electronics or power seat elevation system.

You asked the Plan to pre-approve power wheelchair expandable controller (E2377), power wheelchair expandable controller harness (E2313), power wheelchair electronic connection (E2311) and power seat elevation system (E2300). You say that the enrollee needs a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says seat elevation systems are statutorily non-covered and there is not a medical need to control the power options through the joystick.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The record shows upper limb strength and function are adequate for the enrollee to control the power options using their own switches which are included in the allowance of the power options and power seat elevation systems are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of power wheelchair expandable controller (E2377), power wheelchair expandable controller harness (E2313), and power wheelchair electronic connection (E2311) and power seat elevation system (E2300) have not been met. Therefore, we decided that the Plan does not have to pre-approve Group 3 power wheelchair upgraded electronics or power seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine foot care provided on December 3, 2020.
You asked the Plan to pay for the routine foot care. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says you do not have a covered condition for these services.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for the routine foot care provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection services without imaging guidance.
You asked the Plan to pre-approve injection services without imaging guidance. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that real-time imaging guidance, fluoroscopy or computed tomography, with the use of injectable radio-opaque contrast material is required for all steroid injections and all transforaminal injections. We looked at the file and Medicare rules. Review of the file does not support that imaging guidance will be used for the requested injection services. Based on this information, we decided that Medicare rules for coverage of injection services without imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve injection services without imaging guidance.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on April 19, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you should not have to pay this copayment because the ER nurse was unable to stop your ear bleeding and recommended you be seen by an otolaryngologist the next day. The Plan denied your request. The Plan says you were charged this copayment 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 $50 copayment for emergency care.

You have been asked to pay a $50 copayment for the ER visit. This copayment applies regardless of the services you receive in the ER. 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 room (ER) visit you had on April 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold pack therapy represented by code 97010 provided on April 2, 2021.
You asked the Plan to pay for code 97010. 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. Code 97010 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the hot or cold pack therapy represented by code 97010 provided on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on March 28, 2019.

You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare guidelines.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the anesthesia services was not filed until January 20, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on March 28, 2019.