Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital analysis of an electroencephalogram (95957).
You asked the Plan to pay for the analysis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of Digital analysis of electroencephalogram (EEG). In addition, it is not appropriate to report 95957 for source localization when there are no spikes to analyze.
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 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). We asked our coder 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 analysis. Our reviewer says that CPT code 95957 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of a Digital analysis of electroencephalogram (EEG), therefore, the service cannot be verified as being performed on July 29, 2019. Also, it is not appropriate to report code 95957 for source localization when there are no spikes to analyze.
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 analysis have not been met. Therefore, we decided that the Plan does not have to pay for the digital analysis of an electroencephalogram (95957).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for radical resection of tumor (eg, sarcoma), soft tissue of
abdominal wall; less than 5 cm (22904) provided April 16, 2019.
You asked the Plan to pay for code 22904. You say that this service was medically necessary. The Plan denied
your request. The Plan says code 22904 is not supported in this case.
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 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 code 22904. Our reviewer says that code
22904 is not supported by the medical records. Our physician reviewer found the medical records submitted do
not include documentation for a radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; less
than 5 cm, therefore the service cannot be verified as being performed on April 16, 2019. The procedural note
describes the excision of a 3 cm mass that appeared to be incarcerated omental fat. It also noted a lipoma that
was transected. Neither of these fit the definition for CPT code 22904.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of code 22904 have not been met. Therefore, we decided that the Plan does not
have to pay for radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; less than 5 cm (22904)
provided April 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on February 6, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the emergency room copayment because you were admitted into the ICU for 4 or 5 days. 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 $90 copayment for each visit for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" category. The record shows you were admitted and discharged from the emergency room on February 6, 2019.
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 emergency room visit provided on February 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 additional physical therapy visits and a re-evaluation.
You asked the Plan to pre-approve 16 additional physical therapy visits and a re-evaluation. You say that the enrollee needs physical therapy for 6 more weeks. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 16 additional physical therapy visits and a re-evaluation. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the goals include reducing pain, restoring function, and educating regarding a home exercise program (HEP) prior to transition towards a home program. Our physician reviewer found there is no indication residual deficits could not be addressed via a home exercise program, given completion of a reasonable number of therapy visits to date.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 16 additional physical therapy visits and a re-evaluation have not been met. Therefore, we decided that the Plan does not have to pre-approve 16 additional physical therapy visits and a re-evaluation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Inspire hypoglossal nerve stimulation.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that procedure code 0466T is considered not reasonable and necessary. The services at issue are Inspire hypoglossal nerve stimulation described by procedure code 0466T. These services are denied by Medicare as not reasonable or medically necessary. Therefore, we decided that the Plan does not have to pre-approve Inspire hypoglossal nerve stimulation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve health club services (S9970).
You asked the Plan to pre-approve health club services. You say that you have a chronic condition and doctors have requested that you be active in the gym, long term physical therapy and massage therapy. The Plan denied your request. The Plan says this service is not covered under your benefit package.
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to pre-approve health club services (S9970).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the member does not have a safe discharge plan and is recommended for post-acute therapy. The Plan denied your request. The Plan says that the SNF admission is not medically necessary.
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 pre-approve SNF care. Our reviewer says that the documentation supports the medical necessity of SNF admission. Our physician reviewer found the member requires skilled therapy services and it is medically reasonable and necessary to provide these skilled services on a daily basis. Additionally, the member requires the necessary services on an inpatient basis and an 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the claim should be paid. The
Plan denied your request. The Plan says the documentation does not indicate services are necessary for
treatment of the enrollee's condition.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
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, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device
(E0652).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine.
You asked the Plan to pre-approve MRI. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for the requested MRI is correct, because there is no documentation to support that there has been a failure of conservative therapy.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested MRI. Our physician reviewer found with intermittent symptoms, and unremarkable examination of the neck, and no trial of physical therapy or pain management, the documentation does not support that an MRI of the cervical spine is 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically necessary. The Plan denied your request. The Plan says necessary services may be provided to this member in a lower level setting.
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 has a chest tube and feeding tube. 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. 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral health services provided on July 10, 2019.
You asked the Plan to pay for the behavioral health 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 behavioral health services provided on July 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient hospital psychiatric care.
You asked the Plan to pre-approve inpatient psychiatric care. You say that it is the position of the enrollee's attending inpatient psychiatrist that the enrollee meets the inpatient level of care criteria. The Plan denied your request. The Plan says the denial of authorization for continued inpatient psychiatric care is correct.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care. Our reviewer says that the enrollee does not meet the Medicare criteria for inpatient hospital psychiatric care. Our physician reviewer found based upon the records provided it was not expected that this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, or delusions and was not showing any behavioral issues. It did not appear medically reasonable and necessary to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. The Plan's denial of inpatient psychiatric services appears appropriate. It does not appear that active treatment is taking place. It does not appear that the services are reasonable expected to improve the enrollee's condition or for the purposes of diagnosis. The entire record is not present and does not include an individualized treatment plan. The enrollee's treatment was supervised and evaluated by a physician. 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 psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient hospital psychiatric care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) x 2), core build up (D2950 x 2), gingival irrigation (D4921 x 2), adjunctive pre-diagnostic testing (D0431), and the drugs or medicaments (D9630) provided from August 6, 2019 to September 19, 2019.
You asked the Plan to pay for the crown and core build up for teeth # 18 and 19, the gingival irrigation, pre-diagnostic testing, and drugs or medicaments. You say that you did not know what was covered per year or month. You say that you did not receive policy information from the Plan so that you would know what was or was not covered. The Plan denied your request. The Plan says the frequency limit has been exceeded for the crowns. The Plan says that 2 crowns per calendar year are covered. The Plan also says that gingival irrigation, pre-diagnostic testing, and drugs or medicaments are not listed as covered services.
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 crowns are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the crowns and core build up for teeth # 14 and 15 on August 6, 2019. The gingival irrigation, pre-diagnostic testing, and drugs or medicaments are not among those covered under this benefit. Additionally, the Plan confirmed that policy information was sent to you on October 18, 2018, prior to you receiving the services. Therefore, we decided that the Plan does
not have to pay for the crown (D2740) x 2), core build up (D2950 x 2), gingival irrigation (D4921 x 2), adjunctive pre-diagnostic testing (D0431), and the drugs or medicaments (D9630) provided from August 6, 2019 to September 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets IRF admission criteria. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician 3 times per week or acute rehabilitation nursing care. While the enrollee may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a rest home visit provided on September 19, 2019.
You asked the Plan to pay for the rest home visit. The Plan denied your request. The Plan says there is no valid referral for this service.
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 a rest home visit provided on September 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 4, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot afford the copayment. The Plan denied your request. The Plan says that this is your contractual responsibility.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for Ambulance services. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the Ambulance 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 ambulance transport provided on October 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient ophthalmology services provided on August 19, 2019 by the out-of-network provider.
You asked the Plan to pay for the outpatient ophthalmology services. You say that this provider has been your doctor since 2004 and he was taken off the network and you was not notified. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 for the outpatient ophthalmology services provided on August 19, 2019 by the out-of-network provider.