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

We decided that the Plan does not have to pay for inpatient hospital services provided from September 16, 2019 to September 26, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan denied your request. The Plan says observation was more appropriate.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the records provided at the time of inpatient admission care at the observation level appeared to be appropriate with the option to move the patient to inpatient status when and if it became clear that the patient's hospital stay would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided from September 16, 2019 to September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for total electric hospital bed and mattress purchased from a
non-participating provider on August 6, 2019.
You asked the Plan to pay for the items. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says the items are not covered under Medicare or the Health
Plan.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the items have not been met. The items are not covered under
Medicare or the Health Plan. Furthermore, the provider is not Medicare certified. Therefore, we decided that
the Plan does not have to pay for total electric hospital bed and mattress purchased from a non-participating
provider on August 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the elbow surgery provided on July 12, 2019.
You asked the Plan to reduce the copayment for the elbow surgery. You say that you should be charged a $100 copayment because you were an ambulatory patient in the hospital. 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 $200 copayment for each Medicare-covered outpatient hospital facility visit. You have been asked to pay a $200 copayment for the elbow surgery. The elbow surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows this service was performed at an outpatient hospital.
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 elbow surgery provided on July 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 30,
2018 to October 2, 2018.
You asked the Plan to pay for the acute inpatient hospital care. You say that the acute inpatient hospital care
provided was medically necessary. The Plan denied your request. The Plan says the acute inpatient hospital
care provided was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found the enrollee presented to the emergency department reporting chest pain.
At the time of admission, the enrollee had stable vital signs and no complaints. Care provided to the enrollee
was observation level. There were no advance interventions or complex medical conditions. The
documentation does not support that it was reasonable for the admitting physician to expect that the enrollee's
necessary hospital care would span two midnights. Medical necessity has not been determined.
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 acute inpatient hospital care have not been met. Therefore, we decided that
the Plan does not have to pay for the acute inpatient hospital care provided September 30, 2018 to October 2,
2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit, and it is not approved.
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 the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there is no identified skilled nursing or physical therapy need. When Home Health Aide services are requested and are not in support of a skilled need, the service is not considered medically reasonable or necessary. Additionally, there is no evidence that you are homebound as you are being seen on an outpatient basis and are ambulatory with a cane. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair glide.
The enrollee asked the Plan to pay for a stair glide. The enrollee said that the stair lift was medically necessary
for her to complete daily living functions. The enrollee stated that they needed the stair lift in order to get to
their room as well as the bathroom. The Plan denied the enrollee's request. The Plan says this item is not a
covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift 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 pay for a stair glide.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on August 2, 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 given the procedure performed, there is no medical necessity for TIVA anesthesia to be administered by a separate provider.
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 pay for the services. Our reviewer says that the services at issue in this case are not medically reasonable or necessary. Our physician reviewer found based on the provided medical records justification for the anesthesia for the epidural nerve block procedure on 8/2/2019 is not documented. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services provided to the enrollee on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided to the enrollee on July 16, 2019 and billed under code 64636LT.
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 Current Procedural Terminology (CPT) code 64636 LT (2 Units) indicates destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint. The submitted medical records indicate that procedure was performed on the lateral branches of S1, S2 and S3. The Plan states CPT code 64640, which is a more appropriate code for this service, can be billed for the procedure performed. The Plan states the billed service and units cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, code 64636LT cannot be paid as billed based on insufficient medical record documentation. In addition, there is a question as to whether or not this was the code that should have been billed. The Plan has requested additional medical records and gave direction on the more appropriate codes to be billed for this procedure. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for injection services provided to the enrollee on July 16, 2019 and billed under code 64636LT.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the services provided were medically necessary. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 26, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that an ambulance was called for you because you were unconscious. You say the responders treated you and you began to feel better. Since you felt normal, you refused transportation to the hospital. You say that you did not realize you would be responsible for the ambulance bill. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 4, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the routine transportation to your neurosurgeon (trip of at least 64.2 mile).
You asked the Plan to pre-approve the routine trip. You say that you need to get to this appointment. The Plan denied your request. The Plan says you do not have coverage for transportation of more than 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the routine transportation when each trip is less than 50 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of the routine trip have not been met. Therefore, we decided that the Plan does not have to pre-approve the routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient services provided from March 20, 2018 to March 28, 2018.
You asked the Plan to waive the copayment for the inpatient services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $345 per-day copayment for inpatient days 1 through 5 for Inpatient Hospital Care. You have been asked to pay a $345 per-day copayment for inpatient days 1 through 5 (for a total of $1725) for the inpatient services. The inpatient services fall within the Inpatient Hospital 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 inpatient services provided from March 20, 2018 to March 28, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge day management services provided on February 21, 2019 billed with code 99239.
You asked the Plan to pay for the billed discharge management services. You say that the records support the billing of this code. The Plan denied your request. The Plan says this is a time-based code and no time was documented in the record.
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, there is no documentation that 31 minutes or more were spent providing this service. Based on this information, we decided that Medicare rules for coverage of the billed discharge management services have not been met. Therefore, we decided that the Plan does not have to pay for the discharge day management services provided on February 21, 2019 billed with code 99239.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the mental health care visits provided from July 23, 2019 to August 28, 2019.
You asked the Plan to reduce the copayments for the mental health care visits. You say that you were told you would have a $10 copayment per visit. You say if you had known it was a $40 copayment, you would not have started with the doctor. 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 $40 copayment per provider per day for in-network outpatient mental healthcare from other Medicare-eligible providers. You have been asked to pay a $40 copayment for each of the mental health care visits. The mental health care visits fall within the "Outpatient mental health care" benefit category. The record shows the provider is a clinical psychologist.
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 copayments for the mental health care visits provided from July 23, 2019 to August 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the chest.
You asked the Plan to pre-approve the chest CT. You say that this imaging is needed. The Plan denied your request. The Plan says there are no remaining symptoms for which this imaging is required.
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 the chest CT. Our reviewer says that the requested imaging is not considered medically reasonable and necessary. Our physician reviewer found the enrollee was diagnosed with community acquired pneumonia and initially treated with doxycycline. Symptoms did not fully resolve and she had a chest x-ray which showed no abnormalities. She was treated with Levaquin and now feels well with no residual symptoms. There are no focal lung findings on exam and per the submitted office notes, the recent pneumonia is resolved. There are no symptoms referable to the chest and no abnormal findings on recent chest x-ray. CT scan of the chest is not medically reasonable or 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 chest CT have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D-rendering with interpretation and reporting (76376)
provided on August 27, 2019.
You asked the Plan to pay for 3D-rendering with interpretation and reporting. You say that this was medically
necessary. The Plan denied your request. The Plan says CPT code 76376 is bundled into 93312, 93325, and
93320, which were appropriately reimbursed.
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 pay for 3D-rendering with interpretation and
reporting. Our reviewer says that the requested services are not considered medically reasonable and necessary
in this case. Our physician reviewer found the Interpretation Summary is the same for the 2D and 3D TEE
studies. The documentation does not support that the transesophageal echocardiogram using complete 3D was
medically reasonable and necessary for the enrollee 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 3D-rendering with interpretation and reporting have not been met. Therefore,
we decided that the Plan does not have to pay for 3D-rendering with interpretation and reporting (76376)
provided on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675).
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent
deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not
covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0675, E0673) is a preventive service.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device (E0673, E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the requested orthotics are medically necessary for you. You say that you cannot have surgery because you are on blood thinners. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee on April 26, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met.
Specifically, the claim submitted without an appropriate Treatment Authorization Code and was also not billed with a required G code and Q code for home health claims. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee on April 26, 2019.