Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation you will require a greater than 2 midnight stay.
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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. You are medically stable and have been provided medical clearance to undergo a total shoulder arthroplasty. The planned procedure is not listed on the Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation you will require a greater than 2 midnight stay. The record does not show that at the time of inpatient admission the admitting physician reasonably expects that your necessary hospital care would span two midnights. Our physician reviewer found that your condition does not meet criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81408, 81272, 81246, and G0452 provided on April 6, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 codes 81408, 81272, 81246, and G0452 are not supported in the medical record. Specifically, the performance of multiple molecular tests regardless of whether the requisition lists the tests as a panel or individually and completed on a single sample is considered to be a Panel of tests and should be billed under a single CPT code to prevent stacking of codes. Review of the file does not support that only one code was billed for the services rendered.
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81408, 81272, 81246, and G0452 provided on April 6, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ophthalmological medical examination
and evaluation (92014) and the office visit (99214) provided on August 27, 2020 and September 2, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to
the services provided.
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 $35
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes.
Additionally, you must pay a $35 copayment for each in-person specialist visit.
You have been asked to pay $70. This amount includes a $35 copayment for the Medicare-covered eye exam
and a $35 copayment for the specialist visit provided. 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 ophthalmological medical examination and evaluation (92014) and the office visit (99214) provided on
August 27, 2020 and September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device,
provided on July 30, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the CPAP device. You say that the item should be covered. The Plan denied your
request. The Plan says you obtained this item through an out-of-network provider without prior authorization.
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 continuous positive airway pressure (CPAP)
device, provided on July 30, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a reline complete upper denture (D5730) provided on August 20, 2021.

You asked the Plan to pay for a reline complete upper denture. You say that you have been attempting to get a permanent set of dentures that would last five years for some time. You were told by the provider that the reline was free. The reline is causing you pain. The Plan denied your request. The Plan says you have exhausted your benefit for this service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a reline complete upper or lower denture once per calendar year.

We looked at the file and Medicare rules. The EOC confirms you receive either a complete upper or lower reline denture per calendar year. The records show you received a complete upper and lower reline denture on August 20, 2021, therefore, only one procedure is covered. Based on this information, we decided that the Plan's rules for coverage of a reline complete upper denture have not been met. Therefore, we decided that the Plan does not have to pay for a reline complete upper denture (D5730) provided on August 20, 2021.

Your complaint about the provider's office 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.

You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in 
average volume-assured pressure support mode that could be delivered by BiPAP is not covered.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD.

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 a portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. This patient does not have a neuromuscular 
disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary 
disease. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a 
portable ventilator.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
August 6, 2021, to August 15, 2021.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel you should not 
be responsible for the copayment due to a previous outpatient surgery. The Plan denied your request. The Plan 
says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day, per admission for days 1-6 for in-network covered hospital stays and a $0 copayment per 
day, per admission for days 7-90 for in-network covered hospital stays.

You have been asked to pay a $325 copayment for each day of the inpatient hospital stay. ($325 x 6 days of 
service = $1,950). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the inpatient hospital stay provided from August 6, 2021, to 
August 15, 2021.

The Qualified Independent Contractor read your letter and knows that you may have a quality of care concern. 
The (QIC) cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit for a vision exam provided
on September 8, 2021.
You asked the Plan to waive the copayment for an office visit for a vision exam. You say that the visit should
have been considered a routine vision exam, which is a $0 copayment. The Plan denied your request. The Plan
says according to the records, conditions of the eye were being treated. There is a $40 copayment per visit for
Medicare-covered exams to diagnose and treat diseases of the eye.
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 $40
copayment for Vision Care, Medicare-covered exams.
You have been asked to pay a $40 copayment for an office visit for a vision exam. The vision exam falls within
the Vision Care, Medicare-covered exams 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 office visit for a vision exam provided on September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for collagen cross links (82523) provided on June 9, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for collagen cross links. You say that you called before you took this test to ensure
that it was eligible and would be paid. You also say that at no time did this agent tell you that you needed a
referral from any doctor, so you did not get one, and you are unable to get one so many months after the fact.
The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan
also says that they have also determined that these services were not urgent or emergent, nor were they
approved in advance. The Plan also says that they looked for the phone call to the member referenced in the
appeal, but the phone call was after the date of services.
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 collagen cross links (82523) provided on June 9,
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and
management of an established patient (99336) rendered by the out-of-network (OON) provider on August 13,
2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established
patient (99336) rendered by the out-of-network (OON) provider on August 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0295).

You asked the Plan to pre-approve the semi-electric hospital bed. You say that the semi-electric hospital bed is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that a semi-electric hospital bed is covered if the beneficiary meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate need for a change in body position. 

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 semi-electric hospital bed. Our reviewer says that the semi-electric hospital bed is not medically necessary. Our physician reviewer found while the enrollee meets criteria for a standard hospital bed, the record does not show a need for frequent or immediate changes in body position. 

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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0295).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete bilateral non-invasive arterial ultrasound studies of the upper and lower extremities.
You asked the Plan to pre-approve the arterial extremity studies. You say that both of these studies should be approved to help with management of the patient. The Plan denied your request. The Plan says while the MRA imaging of the head/neck is supported, there is no need for the arterial extremity imaging.
The Plan follows Medicare rules. Medicare rules say that non-invasive vascular imaging may be covered when there are significant signs/symptoms of disease and the imaging is needed for appropriate medical and/or surgical management. 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 arterial extremity studies. Our reviewer says that the documentation does not support the medical necessity of the requested testing. Our physician reviewer found the enrollee is a female with a history of non-ruptured cerebral aneurysm. The enrollee has been authorized to undergo magnetic resonance angiography (MRA) of the head and neck. She has previously had this same imaging in 2015. As such, at this time the requested noninvasive arterial ultrasound imaging would not be considered medically reasonable and necessary in this patient's clinical management. 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 arterial extremity studies have not been met. Therefore, we decided that the Plan does not have to pre-approve complete bilateral non-invasive arterial ultrasound studies of the upper and lower extremities.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80157, 80177, 80201,
80162, 80159 and 80173) provided to the enrollee on March 9, 2021.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the services are not supported by the records. The Plan states the documentation
submitted did not support that carbamazepine; free testing was performed with blood sampling. The Plan states
blood specimen collection is by venipuncture; however, the lab requisition states a urine specimen was
collected; therefore, the billed service cannot be verified. The Plan states of note, the submitted blood/serum
requisition did not contain the billed test.
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 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 laboratory services. Our reviewer found the
documentation submitted did not support that carbamazepine; free testing was performed with blood sampling.
Blood specimen collection is by venipuncture; however, the lab requisition states a urine specimen was
collected; therefore, the billed service cannot be verified. Of note, the submitted blood/serum requisition did
not contain the billed test. The review has determined that the services were not supported by the records
provided.
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 laboratory services have not been met. Therefore, we decided that the Plan
does not have to pay for the laboratory services (CPT code(s): 80157, 80177, 80201, 80162, 80159 and 80173)
provided to the enrollee on March 9, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve paraesophageal hernia repair surgery for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says that imaging in this case does not support this request.
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 surgery. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found the record indicates that the enrollee has gastroesophageal reflux disease with intolerance to medical
therapy. The record indicates that the enrollee has had imaging with a esophagogastroduodenoscopy that
demonstrated a 5 cm Hill grade IV hiatal hernia. The record provided establishes the medical necessity and
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria
are satisfied.
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve paraesophageal hernia repair surgery for the enrollee.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injection of denosumab (J0897),
provided on July 29, 2021.
You asked the Plan to waive the coinsurance for the injection of denosumab. You say that you should not have
to pay anything. The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for the injection of denosumab. This falls 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
injection of denosumab (J0897), provided on July 29, 2021.