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

We decided that the Plan does not have to pay for surgical services (12014) provided on October 20, 2018.You asked the Plan to pay for surgical services. You say that this was filed timely.The Plan denied your request. The Plan says this claim was received more than a year after the date of service.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 surgical services was not filed until November 13, 2019. 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 surgical services (12014) provided on October 20, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on February 1, 2020.You asked the Planto waive the copayment for an ER visit. You say that you disagree with the charges.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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for an ER visit. An ER visit falls within the emergency 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 an ER visit provided on February 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head rendered on October 16, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRA is covered when 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has dizziness and giddiness. The submitted records do not contain sufficient documentation to support that the MRA is reasonable or medically necessary for the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. 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 magnetic resonance angiography (MRA) of the head rendered on October 16, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve24 physical therapy visits.You asked the Plan to pre-approve24 physical therapy visits. You say that additional visits are medically necessary.The Plan denied your request. The Plan says the enrollee can transition to a home exercise plan.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 24 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the patient has been authorized extensive therapy for this condition and her deficits are not such that she requires 24 more therapy visits beyond what was authorized. Her functional level does not need the unique skills of a professional therapist to safely and effectively provide treatment. Services do not only need to be safely and effectively performed by a therapist, or under the supervision of a therapist. The patient has sufficient authorized therapyto transition to an effective home exercise program.The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 24 physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve24 physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee is not aggressive, and is not planning to hurt self or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services beyond June 3, 2020 were requested for 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 continued services. Our physician reviewer found that active treatment was not taking place. It did not appear that the services were reasonably expected or medically necessary to improve the enrollee's condition, or for the purpose of diagnosis. This enrollee was treated under an individualized treatment plan found in the record. Based upon review of the records, the enrollee could be treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions. He was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome visits (99348) and physical therapy evaluations (97163) provided from July 19, 2019 to July 30, 2019.You asked the Plan to pay forhome visits and physical therapy evaluations. You say that in-home services were needed.The Plan denied your request. The Plan says these codes 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 99348 is home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. The definition of code 97163 is physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. Weasked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for home visits and physical therapy evaluations. Our reviewer says that these codes are not supported. Our physician reviewer found the medical records provided indicates that the services of CPT 99348 were performed by a Registered Nurse. The physician was not present at the time this service was performed;therefore,this service does not meet Medicare criteria for reimbursement consideration. CPT 97163 was performed by a Physical Therapy Assistant (PTA) on July 18, 2019. Per the code description, there is Clinical decision making of high complexity, which does not fall within the scope of a Physical Therapy Assistant.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home visits and physical therapy evaluations have not been met.Therefore, we decided that the Plan does not have to pay forhome visits (99348) and physical therapy evaluations (97163) provided from July 19, 2019 to July 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that this is medically necessary. The Plan denied your request. The Plan says that there are no noted daily skilled complex nursing or therapy needs which would meet the guidelines for continued SNF services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveEliquis tab 5mg for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a Part B drug.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 Plandoes not haveto pre-approveEliquis tab 5mg for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical conditions are chronic and stable, and rehab needs are not complex enough to require coordinated care between therapy disciplines.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable period.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic treatment with the requested provider.
You asked the Plan to pre-approve the chiropractic treatment. You say that you do not want to change providers. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the chiropractic treatment. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve chiropractic treatment with the requested provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network chiropractor.
You asked the Plan to pre-approve these services. You say that the treatment is urgent in nature. The Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network chiropractor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that because of a high risk of falls the enrollee needs a shower chair. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve16 physical therapy (PT) visits (97110).You asked the Plan to pre-approve16 PT visits. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays formedically necessary outpatient therapy.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 16 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is generally not accepted as specific and effective therapy for the enrollee's condition. The enrollee has reached a functional level that no longer requires the skills of a professional therapist. She is at a high functional level and does not need the unique skills of a professional therapist to safely and effectively provide treatment. Services do not only need to be safely and effectively performed by a therapist, or under the supervision of a therapist. The enrollee should be able to transition to a home exercise program with the approved therapy. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 16 PT visits have not been met.Therefore, we decided that the Plan does not have to pre-approve16 physical therapy (PT) visits (97110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 17, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you went for a routine eye exam. You say that just because they found something you now have a copayment. The Plan denied your request. The Plan says the copayment 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 $40 copayment for each in-network specialist visit for Medicare-covered benefits. You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that this was a follow up visit for gliosis and hypertension. 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 office visit provided on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion supplies provided from October 1, 2019 to October 4, 2019.
You asked the Plan to pay for the home infusion supplies. You say that you provided home infusion and the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include a valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The signature of the designee is not legible and the date of delivery does not match the claim date. Therefore, we decided that the Plan does not have to pay for the home infusion supplies provided from October 1, 2019 to October 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast prostheses and mastectomy bras purchased on January 29, 2020 from an out of network provider.You asked the Plan to pay for the breast prostheses and mastectomy bras. You say that the Plan did not inform you authorization was required.The Plan denied your request. The Plan says prior authorization was not obtained.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 has network providers available who can provide the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items.Therefore, we decided that the Plan does not have to pay for the breast prostheses and mastectomy bras purchased on January 29, 2020 from an out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not haveto reimburse you for the cost of a moving into the assisted living facility fromOctober 15, 2019 to December 31, 2019.You asked the Plan to reimburse you for the cost of a moving into the assisted living facility. The Plan denied your request. The Plansays custodial care is not covered under Medicare and is not a supplemental benefit with the Plan.The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.We looked at the file and Medicare rules. Medicare does not cover custodial care. Therefore, we decided that the Plan does not have to reimburse you for the cost of moving into the assisted living facilityfrom October 15, 2019 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the multiple services provided from February 21, 2020 to March 6, 2020. You asked the Plan to waive the copayments for the multiple services. You say that you would like the charges to be reversed and that you are reimbursed for the cost share. The Plan denied your request. The Plan says you have been 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). Your contract with the Plan clearly says that you must pay a $20 copayment for each Medicare-covered visit with an in-network PCP, a $250 copayment each one-way Medicare-covered ambulance transport for in- and out-of-service area, a $90 copayment for each Medicare-covered emergency room visit in- and out-of-service area, and a $20 copayment per day, per provider, for in-network Medicare-covered lab services. You have been asked to pay a total of $475.42 for the multiple services. The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The ambulance ride falls within the "Ambulance services" benefit category. The emergency visits fall within the "Emergency care" benefit category. The laboratory work 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 copayments for the multiple services provided from February 21, 2020 to March 6, 2020.