Persius/hicric huggingface dataset:
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 enrollee is currently undergoing treatment at an acute care hospital (ACH),
having initially presented with dehydration and acute renal injury. The enrollee was subsequently treated for
pneumonia, an empyema and bleeding duodenal ulcers. The enrollee is not currently intubated/ventilated.
There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.
The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can
then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.
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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 12 sessions of physical therpay (PT).
You asked the Plan to pre-approve the additional PT sessions. You say that the enrollee continues to have
subjective improvement from these sessions and it is felt that this should be continued. The Plan denied your
request. The Plan says there is no evidence that continued sessions will improve the enrollee's condition or that
they are necessary to maintain his condition.
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 the additional PT sessions. 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 in this case, there is no indication prior PT has served
to provide sustained, significant improvement in pain and/or function and there is no indication residual deficits
could not be addressed via a home exercise program. Therefore, this request is deemed not medically
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the additional PT sessions have not been met. Therefore, we decided that the
Plan does not have to pre-approve an additional 12 sessions of physical therpay (PT).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the behavioral assessment provided on November 6, 2019. 
 
You asked the Plan to waive the copayment for the behavioral assessment. You submitted your bill for review. The Plan denied your request. The Plan says that the copayment applied correctly. 
 
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 enrollees must pay a $0 copayment for services obtained from a primary care provider or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non physician health care professionals in a primary care provider's office.  
 
The Plan says you must pay $5.55 for a non-radiological diagnostic test. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the behavioral assessment. The behavioral assessment is considered a professional service, which is included in the office visit copayment. Therefore, we decided that the Plan has to waive the copayment for the behavioral assessment provided on November 6, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
October 19, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you didn't ask for the
ambulance. You say that you could have been transferred in your own vehicle. 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 $150 per
trip, each way.
You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport 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 transport provided on October 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan has to pre-approve a knee arthroscopy. 
 
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 a course of physical therapy or other physician-directed exercise program is required prior to having this procedure. 
 
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 surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with right knee pain with associated swelling and buckling. Functional limitations are noted in activities of daily living. Clinical exam findings have documented positive provocative meniscal testing consistent with imaging evidence of complex medial and lateral meniscal tearing. There is radiographic evidence of grade 2 (mild) Kellgren-Lawrence osteoarthritic changes. She has failed to improve with activity modification and medications. Under consideration is a request for right knee arthroscopy with partial medial and lateral meniscectomies and possible chondroplasty. Current evidence based medical literature supports arthroscopic meniscectomy in this enrollee's clinical scenario. There is evidence of mechanical symptoms and positive meniscal testing with imaging evidence of complex medial and lateral meniscal tearing. She had failed reasonable conservative treatment, and has mild degenerative joint disease. Therefore, this request for right knee arthroscopy is reasonable and medical necessity for treatment of her medical condition. 
 
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 preapprove a knee arthroscopy.  
 
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 medical services provided to the enrollee by an out-ofnetwork provider on November 5, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99291 and 99292) provided to the enrollee on September 11, 2019. 
 
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 the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 99291: 
 
Critical care, evaluation and management of the critically ill or critically injures patient, first 30-74 minutes. 
 
CPT 99292: 
 
Critical care, evaluation and management of the critically ill or critically injures patient, 75 minutes or more  
 
We asked our coding 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 the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the documentation submitted does not include a "critical care" progress note for September 11, 2019, therefore this service cannot be verified. Critical care services requires a progress note documenting total time that critical care services were provided, as 99291 is a time-based service. CPT code 99292 is an add-on code, and is only eligible for payment if its primary code (CPT 99291) is also eligible for payment. 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 critical care services (CPT 99291 and 99292) provided to the enrollee on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on January 15, 2020, January 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to you by an out-of-network provider on
January 15, 2020, January 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the HPV test provided on November 21,
2019.
You asked the Plan to waive the copayment for the HPV test. You say that this was done with your pap smear.
You say that this is supposed to be covered annually. 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 $10
copayment for Medicare-covered lab services.
You have been asked to pay a $10 copayment for the HPV test. The HPV test falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. The HPV test is considered a
diagnostic laboratory test. 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 HPV test provided on
November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on February
9, 2019.
You asked the Plan to reduce the copayment for the urgent care visit. You say that you were incorrectly
charged $90 for an out-of-network office visit to a non-specialist physician. You say you should be charged a
$35 copayment. 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 $90
copayment for each covered worldwide urgently needed service.
You have been asked to pay a $90 copayment for the urgent care visit. The urgent care visit falls within the
"Urgently needed services" benefit category. The record shows you were charged for an out-of-country urgent
office 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 reduce the copayment for the urgent care visit provided on February 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided on July 17,
2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration as
this service was billed correctly. The Plan denied your request. The Plan says the documentation submitted did
not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of
consciousness and physiological status.
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 99152 is moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age
5 years or older.
We find that CPT code 99152 is not supported in the record. Specifically, the record does not indicate the
presence of an independent trained observer. Based on this information, we decided that Medicare rules for
coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not
have to pay for moderate sedation services (99152) provided on July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Prec Neo Test Strips (A4253). 
 
You asked the Plan to pre-approve Freestyle Prec Neo Test Strips (A4253). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not covered.  
 
The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations. 
 
We looked at the file, th Plan's contract and Medicare rules. The Plan contract clearly states alternate nonpreferred brand diabetic supply products are not covered unless a doctor provides adequate information that the use of an alternate brand is medically necessary in the enrollee's specific situation. The file does not provide documentation from your treating physician that the requested non-preferred brand, Freestyle Prec Neo test strips are medically necessary. Therefore, we decided that the Plan does not have to pre-approve Freestyle Prec Neo Test Strips (A4253).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 88112-26) provided on December 27, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service was billed twice.
The Plan must follow Medicare rules. Medicare rules say that if the technical and professional components of the service are performed by the same provider, then it is not appropriate to report the components of the service separately. We looked at the file and Medicare rules. The services in question were billed twice for the date of service in question; once as a global procedure and once with modifier -26. As the global procedure contains both the profession and technical components, and was paid by the Plan, it is inappropriate to bill the components separately with modifier -26. 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 the services (CPT 88112-26) provided on December 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical connection for a power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the accessory. You say that this is medically necessary. The Plan denied your request. The Plan says these are needed when two or more actuators are being used. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the accessory. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this accessory is not necessary for the safe and adequate functioning of a power mobility device. It is a convenience item as the wheelchair can function without this accessory. Therefore, the request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the accessory have not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical connection for a power wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 7, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit. 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 a covered benefit. 
 
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/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 office visit provided on January 7, 2020 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 transitional care management services rendered on November 11, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct Place of Service (POS) code. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99495 was billed with POS code 31 for inpatient skilled nursing facility. This POS code is not valid for code 99495, as it describes services rendered after discharge. Therefore, we decided that the Plan does not have to pay for the transitional care management services rendered on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on March 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on March 14, 2019.