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 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 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level or in the home with home health services appears to be more appropriate in this case. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on March 3, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee 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 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 did not pre-approve the laboratory services.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 laboratory services provided on March 3, 2020.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the member would be able to fully benefit and/or participate in an IRF 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from April 17, 2020 through April 21, 2020.You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on April 17, 2020 and discharged on April 21, 2020. You were asked to pay a $225 copayment per day from April 17, 2020 through April 20, 2020, days 1-4 of your inpatient hospital care. You were discharged on April 21, 2020 and there was no copayment charge for the day of discharge. Per your contract there is a $225 copayment per day required for days 1-7. 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 inpatient hospital care from April 17, 2020 through April 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract removal (66984) provided on October 7, 2019.You asked the Plan to pay for the cataract removal. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the service 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 code 66984 is  extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation.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 cataract removal. Our reviewer says that CPT code 66984 does not meet criteria for reimbursement consideration. Our reviewer found the operative report does not document this procedure.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 cataract removal have not been met.Therefore, we decided that the Plan does not have to pay for cataract removal (66984) provided on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided to the enrollee on January 24, 2020.
You asked the plan to pay for this service. You say that this claim should be paid. The plan denied your request. The plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services. The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility. This equipment did not go home with the enrollee. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided to the enrollee on January 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require the transfer to LTACH.
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 does not require services at the proposed LTACH that are not already available at the current facility. There are no services available at the proposed LTACH that are not already provided and covered at the current facility. Awaiting completion of current acute care needs at the current facility, which should take less than 25 days, is recommended. Therefore, this request for LTACH services will be considered 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 5, 2019.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, laboratory requisition, or medical records to support the code billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on December 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyproheptad.You asked the Plan to pre-approve Cyproheptad. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.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 Cyproheptad.Benefits for Cyproheptad 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Metoprolol Succint, Pantoprazole, and Amlodipine Besyprovided on February 27, 2020 and February 28, 2020.You asked the Plan to pay for the Metoprolol Succint, Pantoprazole, and Amlodipine Besy. You say that the Plan representative you met with could see no reason why this claim was denied. You also say that these medications were needed and prescribed by your physician.The Plan denied your request. The Plan says these drugs are self-administered drugs and are not covered by 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 pay for the Metoprolol Succint, Pantoprazole, and Amlodipine Besy provided on February 27, 2020 and February 28, 2020.Benefits for the Metoprolol Succint, Pantoprazole, and Amlodipine Besy may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on January 24, 2020.
You asked the Plan to pay for this service. You say that this visit should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 service 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 out of network physician services provided on January 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 home health skilled nursing visits.
You asked the Plan to pre-approve 6 home health skilled nursing 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 home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 6 home health skilled nursing visits.
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the
medical records provided the documentation does not show that skilled nursing services are required to
effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a
maintenance program to maintain your condition and/or prevent deterioration for the additional six visits
requested.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 6 home health skilled nursing visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 6 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory surgery center services provided on February 12, 2020.
You asked the Plan to pay for the ambulatory surgery center services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 ambulatory surgery center services provided on February 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on March 26, 2020.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that a preventative colonoscopy should be covered with no copay, and that this charge is miscoded. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $225 copayment for a diagnostic colonoscopy performed in an outpatient hospital. This colonoscopy was provided for diagnostic reasons, so the diagnostic colonoscopy copay applies to this claim. You have been asked to pay a $225 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy 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 copayment for a diagnostic colonoscopy provided on March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe nerve conduction studies (NCS) and needle electromyography (EMG) provided on October 21, 2019 billed with one unit of code 95812 and two units of 95886.You asked the Planto pay forthe NCS/EMG testing. You say that it is felt that the records support the services as billed.The Plandenied your request. The Plansaysthe record does not show that NCS was performed on 11-12 nerves. As such, the code 95812 is not supported. Since the primary code is not supported, payment is also denied for the add-on code 95886.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 95812 is Nerve conduction studies; 11-12 studies. The CPT Code Manual definition of code 95886 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).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 the NCS/EMG testing. Our reviewer says that the documentation does not support the billed code for the NCS provided. Our physician reviewer found the enrollee has diagnoses of Lesions of the ulnar nerves, right and left upper limbs, Carpal tunnel syndrome, left upper limb, and Pain in left leg. The documentation does not support that 11 -12 nerves were studied by nerve conduction studies. (9 nerves are documented)Since the billed code 95812 is not payable, payment cannot be made for code 95886 which must is only payable when a valid primary code is also payable. Based on this information, we decided that Medicare rules for coverage of the NCS/EMG testing have not been met.Therefore, we decided that the Plandoes not haveto pay forthe nerve conduction studies (NCS) and needle electromyography (EMG) provided on October 21, 2019 billed with one unit of code 95812 and two units of 95886.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foran anesthetic injection (64450) provided on February 18, 2020.You asked the Plan to pay forthe anesthetic injection. You say that you would like reconsideration because this service was billed correctly.The Plan denied your request. The Plan says it is not appropriate to report unspecified, left, right or bilateral diagnosis codes when the procedure modifier on the claim line does not match the diagnosis code"The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.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 anesthetic injection. Our reviewer says that modifier 50 does not support the diagnosis reported. Our reviewer found a single injections does not support the bilateral modifier.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 anesthetic injection have not been met.Therefore, we decided that the Plan does not have to pay foran anesthetic injection (64450) provided on February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 11, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code. We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for dental services provided on February 17, 2020.
You asked the Plan to pay more for the dental services. You say that you were informed insurance would cover
all but $1,731.50. You say that you were assured there would be no other cost to you. The Plan denied your
request. The Plan says after the annual maximum is exhausted, any remaining charges are your responsibility.
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 Plan is only obligated to pay
$1,000 toward your dental benefits annually. The records show the Plan paid $1,000 toward dental services you
received on February 17, 2020, which exhausted your benefit. This means that the remaining charges are your
responsibility. Therefore, we decided that the Plan does not have to pay more for dental services provided on
February 17, 2020.