Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the transthoracic echocardiography under stress (stress echo)
(93351).
You asked the Plan to pre-approve the transthoracic echocardiography. You say that you are requesting an
appeal for coverage of the exercise stress echo. Given the risk factors and age, you would highly recommend
the stress echo. The Plan denied your request. The Plan says that the documents reviewed is insufficient to
establish medical necessity.
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 transthoracic echocardiography.
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this
case. Our physician reviewer found the review indicates that the enrollee has a history of hypertension and
atrial fibrillation (AFib). The medical records received from the August 31, 2021 office visit indicated that the
enrollee has been getting dizzy and lightheaded with change of position, and one episode of asymptomatic
irregular heart rate that was essentially uncharacterized. Stress Echocardiography may be necessary when the
evaluation could contribute significant information to the patient's condition or treatment plan. The review has
determined that the medical records provided meet the requirements listed in the LCD for Medicare coverage
and the requested service is medically necessary 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 the transthoracic echocardiography have been met. Therefore, we decided that
the Plan has to pre-approve the transthoracic echocardiography under stress (stress echo) (93351).
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on March 9, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you were told that if you were admitted to the hospital, your ambulance copayment would be waived. 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 $240 copayment for ambulance services. You have been asked to pay a $240 copayment for the ambulance services. There is no provision in your contract for a waiver of this copayment even if you are admitted to the hospital. 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 ambulance services you received on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81227, 81226, 81225, 81223) provided June 7, 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 claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple reportable test results, only a single code shall be reported for the procedure. We looked at the file and Medicare rules. In this case, multiple unbundled codes were billed for a single procedure. 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 (81227, 81226, 81225, 81223) provided June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and core buildup
(D2950) provided on May 3, 2021.
You asked the Plan to pay for the crown and core buildup. You say that you thought this would be a covered
service. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
porcelain/ceramic crown (D2740) and core buildup (D2950) provided on May 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on February 15, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges because
you were informed when you signed up with the Plan that you would not owe any copayments. The Plan
denied your request. The Plan says the claims were processed correctly and you are being charged the correct
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 $195
copayment for diagnostic radiological services.
You have been asked to pay the allowed amount of $126.82, which is less than the $195 copayment for a CT
scan. A CT scan 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 a CT scan provided on February 15, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services received from December 29, 2020, to January 1, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you do not recall having to pay a copayment for similar services in the past. 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 $360 copayment per day for days 1-5 for inpatient hospital care.
Records show that you were in the hospital for 3 days. You have been asked to pay a $360 copayment per day for days 1-5 for the inpatient hospital services, for a total of $1080. This copayment applies regardless of what you may have paid in the past. 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 received from December 29, 2020, to January 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on August 25, 2020.

You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you were told that the testing should be free. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $150 copayment for advanced imaging services. 

You have been asked to pay a $150 copayment for myocardial perfusion imaging. Myocardial perfusion imaging 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 myocardial perfusion imaging provided on August 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998)
provided on May 30, 2021.
You asked the Plan to pay for the ambulance service. You say that this service should be covered. The Plan
denied your request. The Plan says no transportation occurred and therefore is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on May 30, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no
transport, (A0998) provided on May 30, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for continued SNF services after May 31, 2021.

You asked the Plan to pay for SNF care. You say that continuation of SNF care is medically necessary. The Plan denied your request. The Plan says that continuation of SNF care is not medically necessary.

The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. 

We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before May 31, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pay for continued SNF services after May 31, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left wrist joint arthroplasty.
You asked the Plan to pre-approve the wrist arthroplasty. You say that this surgery should be allowed to treat the enrollee's condition. The Plan denied your request. The Plan says the services are not considered medically reasonable and necessary in this case.
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 wrist arthroplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for bilateral primary osteoarthritis of first carpometacarpal joints. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. In addition, the formal imaging report was not provided for review. There is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for left wrist joint arthroplasty is 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 wrist arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve left wrist joint arthroplasty.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF care.

You asked the Plan to pre-approve SNF care. You say that you need more skilled nursing. The Plan denied your request. The Plan says medical necessity rules for the requested level of 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not require any skilled nursing or rehabilitation services on a daily basis. You are not expected to make measurable gains within a reasonable and predictable period of time nor do you require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). You do not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you do not require any skilled services on an inpatient basis at a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services rendered on May 26, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 11043 and 11046 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 11043 is debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less. The definition of code 11046 is debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure).
We find that CPT codes 11043 and 11046 are not supported in the medical record. Specifically, the records do not support that tissue debridement was done past the subcutaneous level. 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 debridement services rendered on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with an out-of-network nephrology specialist you had on May 4, 2021.
You asked the Plan to waive the copayment for the out-of-network telehealth nephrology visit. You say that you were told your authorization was good for two years. The Plan denied your request. The Plan says this service was not denied-- this cost represents your copayment for this service.
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 $60 copayment for out-of-network specialty care.
You have been asked to pay a $60 copayment for the out-of-network telehealth nephrology visit. The out-of-network telehealth nephrology visit falls within the out-of-network specialty 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 telehealth visit you had with an out-of-network nephrology specialist you had on May 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on March 31, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were told that
you wouldn't be charged for the service. The Plan denied your request. The Plan says the Medicare ambulance
benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicarecovered
service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on March 31, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998) provided on March 31, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond September 22, 2021.

You asked the Plan to pre-approve the continued SNF stay. You say that you believe that you require ongoing treatment in the SNF setting. The Plan denied your request. The Plan says you began refusing therapy and no longer require daily skilled therapy to maintain your condition.

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 continued SNF stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to an acute hospital with endometrial cancer on 8/14/21 and was transferred to an SNF on 8/19/21. As of 9/20/2021, the enrollee required minimal assistance for upper body activities of daily living (ADLs) and maximal assistance for lower body ADLs. She requires standby assistance with bed mobility and maximal assistance for transfers and is not able to ambulate. She is medically stable with no skilled nursing needs. 

As of the date of denial at issue, she did not need any nursing care other than routine care. Documentation does not support the need for a stay in SNF with daily skilled therapies in an inpatient setting at the current level of progress. The enrollee could have her needs met with less than daily skilled therapy services. 

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 continued SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond September 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on May 27, 2021.
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges because you did not expect to have so many X-rays done. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $50 copayment for X-rays provided at an outpatient hospital facility. The record shows that you received an X-ray at an outpatient hospital facility on May 27, 2021. Therefore, you are responsible to pay the $50 copayment.
You have been asked to pay a $50 copayment for an X-ray. An X-ray 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 an X-ray provided on May 27, 2021.
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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's care needs can be met in a less intensive 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 that 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. 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.