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

We decided that the Plandoes not haveto pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services could be provided in another setting, such as an acute rehab facility, skilled nursing facility, nursing facility, outpatient setting, or home care.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 ACH for a COPD exacerbation. The enrollee is not intubated/ventilated. 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 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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an Arthroscopy (29823) provided on April 23, 2019.You asked the Plan to pay for theArthroscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 29823-RT is not supported by the medical records submitted. The operative report did not include sufficient documentation to meet the guidelines of a surgical shoulder arthroscopy, extensive debridement.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 thiscase, the CPT Code Manual definition of code 29823 is Arthroscopy, shoulder, surgical; debridement, extensive.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 Arthroscopy. Our reviewer says that CPT code 29823 does not meet criteria for billing or reimbursement consideration. Our reviewer found 29823 cannot be substantiated because the degree of debridement is not described in detail.
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 Arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for an Arthroscopy (29823)provided on April 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided on July 27, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the itemsat issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided on July 27, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from August 20, 2019 to August 22, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the acute inpatient hospital care provided from August 20, 2019 to August 22, 2019 was medically necessary.The Plan denied your request. The Plan says that the acute inpatient hospital care provided from August 20, 2019 to August 22, 2019 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was admitted to acute care from 8/20/19-8/22/19 after presenting to the emergency room with complaints of intermittent severe colicky abdominal pain associated with nausea and vomiting and inability to eat. Her initial labs included a hemoglobin of 7.1, lactate level elevated at 3.1 with pyuria and bactiuria. She had a borderline increased band count on differential and there was documented concern forpyelonephritis. She was given Meropenem in the emergency department. She was transfused one unit of packed red cells. She was given enemas and her constipation and abdominal pain resolved. Based on the documentation provided, there was legitimate concern for pyelonephritis and/or colitis as well as her significant anemia along with delirium and encephalopathy with her dementia. At least a two midnight stay in the hospital for these issues seemed reasonably expected.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 been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from August 20, 2019 to August 22, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan has to waive the copayments for the inpatient hospital stay and the specialist office visit. We decided that the Plan does not have to waive the copayment forthe emergency room visit. You asked the Plan to waive the copayments forthe inpatient hospital stay, the emergency room visit, and the specialist office visit. You say that you were not informed of any copayment. You say you are being overcharged.The Plan says that you have been charged the correct cost sharing amount.
We decided that the Planhas to waive the copayments forthe inpatient hospital stay and the specialist office visit.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan submitted incomplete 2018 and 2019 Evidences of Coverage. This means thatthe plan has not shown that the copayment amountsyou are being asked to pay is correct or justified by the health plan contract.Therefore, we decided that the Plan has to waive the copayments forthe inpatient hospital stayand the specialist office visit. We also decided that the Plandoes not have to waive the copaymentforthe emergency room visit.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 2018 contract with the Plan clearly says that you must pay an $80 copayment for emergency care.Therefore, we decided that the Plan does not have to waive the copaymentforthe emergency room visit
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroffice visits (99213, 99214) provided on June 26, 2019 and on August 16, 2019 by out of network providers,You asked the Plan to pay foroffice visits. You say that you are requesting reconsideration of our claim which denied for no authorization. You say that the patient has no established relationship with a primary care physician. You also say that you attached medical records.The Plan denied your request. The Plan says the services are not authorized because the providers are non-network providers who do not work with the member's health plan. The member self-directed for care. The member's primary care provider did not refer for services. The health 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 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 foroffice visits (99213, 99214) provided on June 26, 2019 and on August 16, 2019
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance forthe pharmacy charges. We decided that the Plan does not have to reduce the cost share forthe outpatient hospital visits. You asked the Plan to reduce the cost share forthe outpatient hospital visits and the pharmacy charges. You say that these services should be covered under your inpatient hospital benefit.The Plan says that you have been charged the correct cost sharing amount.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided March 18, 2018 to March 20, 2018.You asked the Plan to pay foracute inpatient hospital care. You say that this admission was warranted and supported by clinical documentation in the medical record.The Plan denied your request. The Plan says the criteria for inpatient admission was not met. The enrollee's condition could have been managed at a lower level of care.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 twomidnights 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 while the enrollee spent two midnights in the hospital, at the time of admission, it was not reasonable to expect that two midnights ofinpatient level care would be medically necessary. The documentation does not support that a second midnight of care was medically necessary. In the absence of pre-procedure instability or peri-procedure complications, two midnights of care were not warranted to perform what is considered to be an outpatient procedure.
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 forthe acute inpatient hospital care provided March 18, 2018 to March 20, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a travel CPAP device.You asked the Plan to pre-approve a travel CPAP device. You say that your current CPAP is heavy and bulky causing pain when you travel.The Plan denied your request. The Plan says durable medical equipment is for home use only and duplicate equipment is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The fileshows that you have the CPAP. YourCPAP serves the same purpose as a travel CPAP device.Therefore, we decided that the Plan does not have to pre-approvea travel CPAP device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve syringe with needle for external insulin pump described by code A4232.You asked the Plan to pre-approvethese services. The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that the supplies related to the use of a covered insulin pump are coded as A4224 and A4225. Code A4232 represents noncovered supplies.Therefore, we decided that the Plan does not have to pre-approvesyringe with needle for external insulin pump described by code A4232.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe neurostimulator insertion providedfrom June 24, 2019 through June 25, 2019.You asked the Plan to waive the coinsurance forthe neurostimulator insertion. You say that you remained in the hospital for longer than 24 hours. You say that you should only be charged the daily rate for inpatient hospitalization.The Plan denied your request. The Plan says you remained in the hospital for longer than 24 hours. You say that you should only be charged the daily rate for inpatient hospitalization.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 20% coinsurance for Medicare-covered surgery or other services provided to you at an outpatient hospital.You have been asked to pay $1,321.60, which is 20% of the billed amount for the neurostimulator insertion. The neurostimulator insertion falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show that this was an outpatient procedure. 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 coinsurance forthe neurostimulator insertion provided from June 24, 2019 through June 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe heart catheterization procedure provided on August 2, 2019.You asked the Plan to waive the copayment forthe heart catheterization procedure. You say that the unpaid portion was part of the procedure. 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 $360 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $360 copayment for the heart catheterizationprocedure. The heart catheterizationprocedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forthe heart catheterization procedure provided on August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal implant, bone replacement graft for ridge preservation, cone beam CT capture and interpretation, radiographic/surgical implant index, and implant procedure.You asked the Plan to pre-approvethe endosteal implant, bone replacement graft, cone beam CT capture and interpretation, radiographic/surgical implant index, and implant procedure. You say that you were told by a representative that the Plan did cover dental implants. You also say that you spoke with another representative who told you that implants were not covered.The Plan denied your request. The Plan says these services are not covered under your plan.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.Thoughthe Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe surgical placement of implant body: endosteal implant, bone replacement graft for ridge preservation, cone beam CT capture and interpretation, radiographic/surgical implant index, and implant procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ophthalmological medical examination and initiation of diagnostic and treatment program (92014) provided on June 27, 2019.You asked the Plan to waive the copayment foran ophthalmological medical examination and initiation of diagnostic and treatment program. You say that this was not a medical eye exam because you have no cataracts. You say youhad cataract surgery several years ago and you should not have been diagnosed with any other medical conditions. You say further that you use the provider strictly for routine eye exams and feel like they lied on the bill. This should have been covered through eye plan.The Plan denied your request. The Plan says Vision Care services have a $20 copayment. The Plan also says the medical records support the codes billed on the claim.Medical records indicate that youhavean ophthalmologic plan in place for diagnoses related to the ocular system. The Plan further says that youhavehad cataract surgery in the past, having the intraocular lens monitored in each eye as it is suspect for retinal detachment and is being monitored for glaucoma.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for Vision Care services. You have been asked to pay a $20 copayment for an ophthalmological medical examination and initiation of diagnostic and treatment program. These servicesfall within the Vision Care services benefit category. The record shows that your provider performed and billed for a medical eye exam. 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 foran ophthalmological medical examination and initiation of diagnostic and treatment program (92014) provided on June 27, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from May 23, 2019 to August 11, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancetdevice provided from May 23, 2019 to August 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe surgical placement of implant body: endosteal implant, abutment supported porcelain fused to metal crown, bone replacement graft for ridge preservation, and extraction.You asked the Plan to pre-approvethe endosteal implant, abutment supported crown, bone replacement graft, and extraction. You say that the enrollee is currently on immunotherapy for his lung cancer.The Plan denied your request. The Plan says neither Medicare nor the enrollee's Medicare Advantage health plan covers these items.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of "the beneficiary" teeth or the structures directly supporting "the beneficiary's" teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvethe surgical placement of implant body: endosteal implant, abutment supported porcelain fused to metal crown, bone replacement graft for ridge preservation, and extraction.