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

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 10, 2019 through June 11, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 inpatient hospital care. Our physician reviewer found the treating physician did not document that the patient was not stable for transfer following the 10 am June 10, 2019 time. Based on the documentation provided, the physician stated that the patient was stable for discharge on June 10, 19, at 9:47 am. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 10, 2019 through June 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an excision (11603) provided on September 18, 2019.
You asked the Plan to pay for the excision. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted Operative Note did not include documentation of Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm was performed.
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 11603 is excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm. 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 excision. Our reviewer says that CPT code 11603 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of an Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 2.1 to 3.0 cm. The medical records do not document the measurements to validate the requirements for billing this code was met, therefore, the service cannot be verified. 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 excision have not been met. Therefore, we decided that the Plan does not have to pay for an excision (11603) provided on September 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) for tooth # 31 provided on October 7, 2019.
You asked the Plan to pay for the extraction of tooth # 31. You say that you contacted the Plan on the morning of your appointment. You say that the Plan representative advised that the provider you were going to see was an approved provider. You also say that you only went to this provider because the Plan told you they were an approved provider. The Plan denied your request. The Plan says the frequency limit has been exceeded. The Plan says 2 extractions per calendar year are covered.
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 and surgical extractions are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the extractions for teeth # 2 and 30 that you received on October 7, 2019. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) for tooth # 31 provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 10, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 physician's services provided on January 10, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for mattress, foam rubber (CPT Code E0272) provided to the enrollee from January 1, 2019 through August 15, 2019.
You asked the Plan to pay for the DME. You say that you are requesting reimbursement of the DME rendered. The Plan denied your request. The Plan says that this item is not covered under Medicare or the Health Plan.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the foam rubber mattress (E0272) have been met. Specifically, the foam rubber mattress is a covered benefit of Medicare. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The Plan has not made reasonable and diligent efforts to forward information to the IRE showing that you do not own a hospital bed or that you do not meet Medicare criteria for this item. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for mattress, foam rubber (CPT Code E0272) provided to the enrollee from January 1, 2019 through August 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the chest (71260) and a CT scan of the abdomen/pelvis (74177).
You asked the Plan to pre-approve a CT scan of the chest (71260) and a CT scan of the abdomen/pelvis (74177). You say that the requested CT scans are medically necessary. The Plan denied your request. The Plan says the requested CT scans are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 a CT scan of the chest (71260) and a CT scan of the abdomen/pelvis (74177). Our reviewer says that the requested CT scans are not medically necessary. Our physician reviewer found the enrollee is with diffuse large cell lymphoma who has completed chemotherapy in 2019. Surveillance CT scans have been ordered. Per NCCN guidelines DLBCL 1.2020, repeat CT scans are only approved as clinically indicated, not for surveillance. In this case, the requested CT scans are 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 a CT scan of the chest (71260) and a CT scan of the abdomen/pelvis (74177) have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest (71260) and a CT scan of the abdomen/pelvis (74177).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 17, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 physician's services provided on July 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the Head (70450) provided September 2, 2019.
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. 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. We find that CPT code 70450 is not supported in the medical record. Specifically, there is no evidence that the enrollee had two distinct and independent CT scans of the head without contrast on September 2, 2019. Two CTs were ordered, but one was performed on September 2 and the other on September 3, 2019. Therefore, the billing of a second and distinct procedure on September 2, 2019 is not supported. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the Head (70450) provided September 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visits you had on August 22, 2019, and October 3, 2019, and pay for the eye refraction you had on August 22, 2019.
You asked the Plan to waive the services. You say that your new glasses don't help. The Plan denied your request. The Plan says you are responsible for the cost share.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers vision specialist visits with a $40 copayment. We looked at the file and the Plan's rules. The records show that you had two specialist visits on August 22, 2019, and October 3, 2019. You are responsible for a $40 copayment for each visit, totaling $80. Additionally, the eye refraction you received on August 22, 2019, is not covered by Medicare or your plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist visits you had on August 22, 2019, and October 3, 2019, and pay for the eye refraction you had on August 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 8, 2019 to August 6, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from July 8, 2019 to August 6, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sleep monitoring in a sleep lab (95811).
You asked the Plan to pre-approve sleep monitoring in a sleep lab. 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. 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 sleep monitoring in a sleep lab. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided the follow-up titration sleep study (95811 - sleep staging with 4 or more parameters) is not medically reasonable and 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 sleep monitoring in a sleep lab have not been met. Therefore, we decided that the Plan does not have to pre-approve sleep monitoring in a sleep lab (95811).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 13, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 physician's services provided on August 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve robotic knee surgery. 
 
You asked the Plan to pre-approve robotic knee surgery. You say that you have found that robotic-assisted knee replacement has better outcomes. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is insufficient literature to support the use of robotic knee replacement. 
 
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 robotic knee surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found robotic surgery remains experimental. More research is needed to show the safety and efficacy of this service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of robotic knee surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve robotic knee surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for urinary catheters (A4351) provided on September 16, 2019.
You asked the Plan to pay for the urinary catheters. You say that you would like reconsideration as the supplies are medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include a Physician's Order to indicate the specific supplies for the billed date of service.
The Plan must follow Medicare rules. The rules state that the delivery date/date of service must be within 3 months from the "Initial Date" of the CMN or DIF or 3 months from the date of the physician's signature. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. Specifically, the delivery date of September 16, 2019 is 3 months beyond the initial date of the order. Therefore, we decided that the Plan does not have to pay for urinary catheters (A4351) provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facility fee on September 18, 2019.
You asked the Plan to waive the copayment for the facility fee. You say that you were not informed there would be an additional fee. You say that the fee should be avoided. 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 when you visit a provider, you may be charged a "facility fee." This fee reflects a trend in hospitals buying doctors' practices and adding "facility fees" to patient bills. In those cases, the outpatient cost-share applies to the services (see below for cost-share information). Your contract with the Plan clearly says that you must pay a $325 copayment for each Medicare-covered non-surgical visit in an outpatient clinic. You have been asked to pay a facility fee of $133.75, which is less than the standard $325 copayment for an outpatient hospital visit. The facility fee falls within the "Outpatient hospital 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 facility fee on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on June 16, 2019 to July 1, 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 procedure codes 99239 and 99291 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 99239 is hospital discharge day management; more than 30 minutes. The denial of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT codes 99239 and 99291 are not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of hospital discharge services spent on the enrollee to support code 99239 and no documentation of 30-74 minutes of critical care spent on the enrollee to support code 99291. 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 services rendered to the enrollee on June 16, 2019 to July 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on April 5, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on April 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services coded 99239 provided on July 21, 2019.
You asked the Plan to pay for the hospital discharge day management services. 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 supported by the documentation.
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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted did not support a hospital discharge day management service of 30-74 minutes was performed. The documentation does not include the time spent providing this service. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services coded 99239 provided on July 21, 2019.