Persius/hicric huggingface dataset:
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 this is not medically necessary.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the unspecified periodontal procedure (D4999) and the unspecified fixed prosthodontic procedure (D6999).

You asked the Plan to pre-approve the unspecified periodontal procedure and the unspecified fixed prosthodontic procedure. You say that the services are requested to treat an underlying infection and to preserve natural teeth. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.

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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the unspecified periodontal procedure (D4999) and the unspecified fixed prosthodontic procedure (D6999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided from February 24, 2021, to February 25, 2021.

You asked the Plan to pay for Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no documentation of critical care time spent to corroborate the services.

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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, this is a time-based CPT code and there is no documentation of the total time critical care services were provided. Based on this information, we decided that Medicare rules for coverage of Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services provided from February 24, 2021, to February 25, 2021.
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 this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

You were admitted for spinal stenosis surgery in June 2021 and was discharged home with home health services. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99205, 88321, 99215) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON office visits. You say that you believe you will get the best care from the requested provider. The Plan denied your request. The Plan says the requested services are available in-network.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits (99205, 88321, 99215) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiography provided on January 3, 2020 by an out of network (OON) provider.

You asked the Plan to pay for an echocardiography. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 had network providers available who could have provided the items/services at issue in this appeal.

The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an echocardiography provided on January 3, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities, each 15 minutes (97530) provided
December 24, 2020.

You asked the Plan to pay for the therapeutic activities. You say that many of the requested services in 2020
are not available on an outpatient basis secondary to the recent COVID-19 virus pandemic Please review all
attached documentation supporting the request and process the claim for payment. The Plan denied your
request. The Plan says the records do 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 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.

We find that CPT code 97530 is not supported in the medical record. Specifically, the records indicate that the
service is performed by an occupational therapist assistant in a home health or hospice setting. There is an
appropriate HCPCS code (G0158) for the billed service. The plan made multiple attempts to contact the
provider for additional information. Based on this information, we decided that Medicare rules for coverage of
the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the
therapeutic activities, each 15 minutes (97530) provided December 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient cataract surgery (66984) provided on March 2, 2021.
You asked the Plan to waive the copayment for outpatient cataract surgery. You say that the cost of your surgery should be covered in full once the copayment is paid. 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 $390 copayment for outpatient hospital services.
You have been asked to pay a $390 copayment for outpatient cataract surgery. The EOC confirms $390 is the
required copayment for this service. Outpatient cataract surgery 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 outpatient cataract surgery
(66984) provided on March 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PBT.
You asked the Plan to pre-approve the PBT. You say that you would like reconsideration because PBT is medically necessary. The Plan denied your request. The Plan says intensity-modulated radiation therapy would be the standard of care in this case.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PBT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found normal tissue dose volume histograms (DVHs) must be demonstrably improved with a PBT plan to validate coverage. No DVH comparison has been provided. 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 PBT have not been met. Therefore, we decided that the Plan does not have to pre-approve PBT.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on November 18, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided to you on November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee still requires significant respiratory support, still oxygenated and positive for COVID. The Plan denied your request. The Plan says the stay is not medically necessary.

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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. The documentation does not support that an additional twenty-five (25) days of hospitalization are reasonably expected for the enrollee in this case. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.

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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the x-ray exam of the shoulder (73030) and the laboratory services provided on January 25, 2021 and February 5, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services provided.

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% coinsurance for laboratory services and basic radiological services provided at an in-network outpatient hospital.

You have been asked to pay $63.87 ($105.64 x 20% coinsurance=$21.13) for the basic radiological service and ($213.68 x 20% coinsurance=$42.74) for the laboratory services provided at an in-network 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 waive the coinsurance for the x-ray exam of the shoulder (73030) and the laboratory services provided on January 25, 2021 and February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the prophylactic, therapeutic, or diagnostic injection (96372) and the vitamin b-12 cyanocobalamin injection (J3420) provided on March 16, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services provided.
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% coinsurance for Medicare Part B drugs. You have been asked to pay $3.09 ($15.44 x 20% coinsurance) for the Medicare Part B drug injections provided. 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 for the prophylactic, therapeutic, or diagnostic injection (96372) and the vitamin b-12 cyanocobalamin injection (J3420) provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 15, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for alginate dressing (A6196) and gauze (A6219, A6220) provided on March 11, 2021, by an out of network (OON) provider.
You asked the Plan to pay for wound supplies. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for alginate dressing (A6196) and gauze (A6219, A6220) provided on March 11, 2021, by an out of network (OON) provider
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physician services provided on December 30,
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 30, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that the prostate test should be covered 100%. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $50 copayment for specialist services. 

The medical records show that you received specialist services on March 30, 2021. Therefore, you are responsible to pay the $50 copayment. 

You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on March 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening.

You asked the Plan to pre-approve the requested LDCT scan. You say that the service is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. We reviewed the file and the Medicare rules. We find that the enrollee quit smoking seventeen (17) years ago. Therefore, we decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening.