Persius/hicric huggingface dataset:
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 disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found you were admitted to the hospital with a stroke. You are now medically stable with no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care provided to the enrollee from January 6, 2022, forward.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says your request does not meet Medicare guidelines because you no longer require skilled services on a daily basis and the continuation of SNF is not medically necessary.
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 you no longer qualifies for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are consistently ambulating more than one hundred (100) feet. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower 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 continuation of SNF care provided to the enrollee from January 6, 2022, forward.
Appeal type: Testing
Decision: Favorable

We decided the Plan must pre-approve a diagnostic colonoscopy (45378) and monitored anesthesia (00811).
You asked the Plan to pre-approve a diagnostic colonoscopy. You say that a diagnostic colonoscopy is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. The Plan says the enrollee just had a colonoscopy in 2019. A small noncancerous polyp was removed, and the enrollee does not need a repeat colonoscopy in just two years.
The Plan follows Medicare rules. Medicare rules say that a diagnostic colonoscopy and monitored anesthesia are indicated for evaluation of unexplained gastrointestinal bleeding: hematochezia that is not from the rectum or a perianal source. 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 this service. Our reviewer says that a diagnostic colonoscopy and monitored anesthesia are medically necessary. Our physician reviewer found that LCD L34213 criteria are met in this case for the proposed services for evaluation of the enrollee's hematochezia of uncertain origin. 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 diagnostic colonoscopy have been met. Therefore, we decided that the Plan has to pre-approve a diagnostic colonoscopy (45378).
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: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for the medical services provided from March 1, 2021, through March 4, 2021, coded as 99232 x3, 44140, and 50715-59. We decided that the Plan does not have to pay for the services described by 49000-59.
You asked the Plan to pay for the medical services provided from March 1, 2021, through March 4, 2021, coded as 99232 x3, 44140, and 50715-59. You say that this should be paid as billed. The Plan says that no decision was made on most of the codes, but 49000 was correctly denied since it is bunded with 44140 and no modifier is allowed.
We decided that the Plan has to pay for the medical services provided from March 1, 2021, through March 4, 2021, coded as 99232 x3, 44140, and 50715-59.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. We find that the Plan did not make reasonable and diligent efforts to forward information regarding the denial of these services. The Plan stated that these other codes were not appealable as they are being handled as a first-level claim review. Since this claim was denied and appealed, first-level claim review ended. These codes must be reviewed at the appeal level. Since the Plan also did not provide any rationale to support non-payment for these services, we find that the rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for the medical services provided from March 1, 2021, through March 4, 2021, coded as 99232 x3, 44140, and 50715-59.
We also decided that the Plan does not have to pay for the services described by 49000-59.
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, code 49000 is a Column 2 code in relation to 44140. The modifier indicator of this edit is 0. This means that these codes cannot be paid together even if a modifier is used. Therefore, we decided that the Plan does not have to pay for the services described by 49000-59.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinalysis coded 81002 provided on April 20, 2021.
You asked the Plan to pay for the urinalysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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, we have confirmed that code 81002 for the urinalysis is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the urinalysis coded 81002 provided on April 20, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided by on November 9, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were treated for coronavirus-related symptoms and should not be charged a copayment. 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 $120 copayment for Medicare-covered emergency room visits.
You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you were charged for a chest x-ray and the emergency room visit. 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 visit provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on July 26, 2021.
You asked the Plan to waive the copayment for the medical eye exam. You say that you were told that the provider was in-network. 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 $65 copayment for each out-of-network Medicare-covered exam.
You have been asked to pay a $65 copayment for the medical eye exam. The medical eye exam falls within the "Vision Care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The record shows the provider is out-of-network. 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 medical eye exam provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on June 24, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you would like to appeal the $20 copayment for the follow-up visit. 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 $20 copayment for each Medicare-covered specialist visit.
You have been asked to pay a $20 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided on June 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gocovri.
You asked the Plan to pre-approve Gocovri. You say that this is the appropriate therapy for this enrollee. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
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 Gocovri.
Benefits for Gocovri 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer to SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says your request does not meet Medicare guidelines because you are receiving adequate and necessary intensive rehabilitation in the inpatient rehabilitation facility (IRF). The Plan states all the services you need are offered at the IRF. The Plan states transfer to a SNF for inpatient skilled rehabilitation services is not medically necessary.
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 there is documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are required to safely and effectively provide medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are required. You do not require the services on an inpatient basis, only in a SNF setting. Continued care in the acute inpatient rehabilitation facility is appropriate (and endorsed by the health plan) until you are stable to transfer to a lower 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 transfer to SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to adjust the $50 copayments for out of network physical therapy to
$20 for services provided from March 8, 2021, to April 13, 2021.
You asked the Plan to adjust these copayments. You say that your provider told you that you should only be
paying $20 per session. The Plan denied your request. The Plan says the contract is clear that out of network
services have a $50 copayment. Maximus overturned the Plans denial administratively for insufficient
information in the case file. The Plan requested a reopen and provided additional information. The Plan
provided call records from your provider. These records show the provider stated they counseled you that if
you wanted to reduce your copayment to $20 you would have to see an in-network provider.
The Plan is correct in this case. 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 $50 copayment for out of network rehabilitation services.
The records show you were counseled by the provider on how to interpret your Plan contract regarding in and
out of network copayments. 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 adjust the $50 copayments for out of network physical therapy to $20
for services provided from March 8, 2021, to April 13, 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 would benefit from and can tolerate IRF level of care. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met.
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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 the 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) provided on September 3, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services provided in this case are not a covered 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 services provided in this case are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive this $10 copayment charged for an office visit provided on
February 15, 2021.
You asked the Plan to waive this cost share. You say that this was your annual exam and should be no charge.
The Plan denied your request. The Plan says the records show there were services billed by your provider
beyond the annual exam that would incur cost share. We overturned the Plans denial for insufficient
information in the case file. The Plan requested a reopen and provided additional information. The Plan says
that the records show the claim submitted by the provider was for diagnosis and counsel for essential
hypertension, hyperlipidemia, evaluation of low back pain, varicocele, screening counsel for colon cancer,
aortic aneurysm, and prostate cancer.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay a $10 copayment for a
physician office visit. Your provider billed the Plan for an annual exam as well as additional physician services
which incurred the $10 copayment. The Plan has paid its share of this claim. 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 this $10
copayment charged for an office visit provided on February 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Simponi.

You asked the Plan to pre-approve Simponi. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.

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 Simponi.

Benefits for Simponi 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 pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.