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

We decided that the Plan does not have to waive the copayments for an outpatient hospital stay, outpatient
surgery, and outpatient specialist office visits provided from June 28, 2021, to July 3, 2021.

You asked the Plan to waive the copayments for an outpatient hospital stay, outpatient surgery, and outpatient
specialist office visits. You say that you have been receiving an overabundance of claims regarding an inpatient
hospital stay for the member starting from June 28, 2021, to July 3, 2021. You also say that each claim
involved office visits despite the member being an inpatient in the hospital and you did not have to go through
this issue during his last inpatient hospital stay. You also say that you feel that the bills should be processed as
he was an inpatient. The Plan denied your request. The Plan says you were 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). The enrollee's contract with the Plan clearly says that unless the
provider has written an order to admit the enrollee as an inpatient to the hospital, the enrollee is an outpatient
and pays the cost sharing amounts for outpatient hospital services. The enrollee's contract with the Plan also
says that even if the enrollee stays in the hospital overnight, he/she might still be considered an "outpatient."
The Plan contract also clearly says that if the enrollee is unsure if he/she is an outpatient, the enrollee should
ask the hospital staff. The enrollee's contract with the Plan also clearly says that enrollees must pay a $325
copayment per stay for outpatient observation stays. The Plan contract also says that enrollees must pay a $325
copayment per date of service for outpatient hospital facility. The Plan contract also says that enrollees must
pay a $40 copayment per specialist visit for physician/practitioner services, including doctor's office visits.

The enrollee has been asked to pay a $325 copayment for an outpatient hospital stay. Outpatient hospital stays
fall within the outpatient observation stays benefit category. You have also been asked to pay a $325
copayment for outpatient surgery. You have also been asked to pay a $40 copayment for each outpatient
specialist office visit. Outpatient specialist office visits fall within the physician/practitioner services, including
doctor's office visits. The record shows that this was not an inpatient hospital stay, but an outpatient hospital
stay. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan.
This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore,
we decided that the Plan does not have to waive the copayments for an outpatient hospital stay, outpatient
surgery, and outpatient specialist office visits provided from June 28, 2021, to July 3, 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. The Plan denied your request. The Plan says it is not reasonable that the enrollee would fully benefit from the intensity of services of an IRF.

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 physician reviewer found that the enrollee was admitted to the acute care hospital for hyperkalemia and acute kidney insufficiency. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support,
emergency transport (A0429) provided June 11, 2021.
You asked the Plan to waive the copayment for the emergency ambulance service. You say that you don't feel
you should be responsible for the ambulance copayment because you received terrible medical care at the
hospital. The Plan denied your request. The Plan says the copayment was applied to correctly to the service
rendered.
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 $250
copayment for each one-way Medicare-covered ground trip.
You have been asked to pay a $250 copayment for the emergency ambulance service. The emergency
ambulance service falls within the Ambulance services benefit category. This means that you have been asked
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive
the copayment for the ambulance service, basic life support, emergency transport (A0429) provided June 11,
2021.
Your complaint about the Plan inadequately addressing your concerns is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on March 12,
2021.
You asked the Plan to pay for the critical care services provided on March 12, 2021. You say that the services
should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the
last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify
the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare
Advantage member on hospice.
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 the critical care services (99291) provided on March 12,
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because the requested Prolia is medically necessary to treat the member's condition. The Plan denied your request. The Plan says the provider has indicated that the requested drug will be dispensed by a pharmacy.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.

Benefits for Prolia 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for alcohol biomarker testing provided on January 6, 2021.
You asked the Plan to pay for lab test. You say that this test provides valuable information for physicians to use
in determining the appropriate treatment. The Plan denied your request. The Plan says the denial of payment
for this service is correct, because code 80321 is not valid for Medicare purposes and is not payable.
The Plan must follow Medicare rules. Medicare rules say that code 80321 is not valid for Medicare purposes
and is not payable.
We looked at the file and Medicare rules. This code is not valid for Medicare purposes and is not payable.
Based on this information, we decided that Medicare rules for coverage of lab test have not been met.
Therefore, we decided that the Plan does not have to pay for alcohol biomarker testing provided on January 6,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus blood glucose test strips (A4253).

You asked the Plan to pre-approve Accu-Chek Aviva Plus test strips. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for the requested brand of durable medical equipment have not been met.

The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred brands and manufacturers. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Accu-Chek Aviva Plus test strips have not been met. Specifically, the requested items are a non-preferred brand. The case record does not contain medical documentation that supports the medical necessity of the requested items. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus blood glucose test strips (A4253).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Octagam.
You asked the Plan to pre-approve Octagam. You say that the goal of the treatment is to keep the enrollee
stable and out of the hospital. The Plan denied your request. The Plan says the coverage requirements have not
been met.
The Plan must follow Medicare rules. Medicare rules say that intravenous immunoglobulin is only covered
under certain medical indications.
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 Octagam. Our physician reviewer found
that in this case, the enrollee has a history of myasthenia gravis. At the present time IVIG is supported for use
in the acute treatment of myasthenia gravis (or for myasthenic crisis). The enrollee is using IVIG as
maintenance therapy, which is not an indication for which its use is supported in the LCD, the FDA approved
labeling or the Compendia. In this context, medical necessity cannot be established.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Octagam have not been met. Therefore, we decided that the Plan does not have
to pre-approve Octagam.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services provided to the enrollee on April 16, 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 Current Procedural Terminology (CPT) code 99239 (1 Unit) remains 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 99239 is "Hospital discharge day management; more than 30 minutes." 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation does not support more than 30 minutes of time was spent, as no time was found in the documentation. Therefore, this procedure code cannot be confirmed.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services provided to the enrollee on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subarachnoid opioid injection provided on October 11, 2021.
You asked the Plan to pay for the subarachnoid opioid injection. You say that the Plan's rationale is incorrect as it references epidural steroid injections which is not the service rendered. This injection was not epidural but subarachnoid and was of opioids. This is considered to be very effective in this enrollee's pain condition. The Plan denied your request. The Plan says there are no records to support whether this treatment was necessary.
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient documentation which corroborates the documentation in the beneficiary's medical documentation and confirms that Medicare coverage criteria have been met. In this case, no medical records were submitted with this appeal. As such, we are not able to confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the subarachnoid opioid injection provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical rehabilitation services provided from April 6,
2020, through May 26, 2020.
You asked the Plan to pay for the medical rehabilitation services. You say that you would like an exception to
be made for this untimely claim. The Plan denied your request. The Plan says this claim was filed after the
timely filing dates.
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 medical rehabilitation services was not filed until June 16, 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 medical rehabilitation services provided from
April 6, 2020, through May 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says observation is appropriate.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee presented to the emergency room after a fall. He had evidence of a chronic L4 compression fracture; creatinine was 2.73. He had difficulty with ambulation. He received pain control, intravenous fluids, and physical therapy. The review has determined that the record did not show that the enrollee's necessary hospital care would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an out-of-network surgery provided on August 24, 2021.

You asked the Plan to waive the deductible for the out-of-network surgery. You say that the services should be covered as they were in-network. The Plan denied your request. The Plan says the cost-sharing applied correctly, and the services were rendered out-of-network.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible and a 40% coinsurance which applies to Outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers.

The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible and a 40% coinsurance which applies to Outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time the out-of-network surgery was received on August 24, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an out-of-network surgery provided on August 24, 2021.

Since the deductible was met, you have also been asked to pay a 40% coinsurance for the surgery (allowed is $3,953.68 x 20% = $1.581.47). 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 surgery provided on August 24, 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 the enrollee will optimize his level of functioning prior to returning home. The Plan denied your request. The Plan says the enrollee does not require an interdisciplinary team approach to rehabilitation care.

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 physician reviewer found that the enrollee was admitted to the acute care hospital for a diabetic foot ulcer and had a transmetatarsal amputation. His medical problems are stable. He does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While he has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. The complexity of hi nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (27345, 29875) provided September 28,
2020.

You asked the Plan to pay for the surgical 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 27345, & 29875 is not supported in the medical record. Specifically, the medical
records provided do not include sufficient documentation to validate that an excision of synovial cyst of
popliteal space (Baker's cyst) was performed. CPT 29875 is inclusive to CPT 29880 which was also billed.
Based on this information, we decided that Medicare rules for coverage of the surgical services have not been
met. Therefore, we decided that the Plan does not have to pay for surgical services (27345, 29875) provided
September 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cinacalcet 60mg tablet 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 this self-administered drug does not fall under Part B coverage.

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 Cinacalcet 60mg tablet 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 you will be able to get your strength back. The Plan denied your request. The Plan says you do not meet the criteria for admission.

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 physician reviewer found that you were admitted to the acute care hospital for coronary artery bypass grafting. Your medical problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.