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

We decided that the Plan does not have to waive the copayments for the inpatient hospital stay from February 11 through February 19, 2021.
You asked the Plan to waive the copayments for the inpatient hospital stay. You say that you disagree with how the hospital stay was coded. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $165 copayment per day, for days 1 through 10 for Inpatient Hospital Care. You have been asked to pay a $1,320 in copayments ($165 per day) for the inpatient hospital stay. The inpatient hospital stay falls 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 copayments for the inpatient hospital stay from February 11 through February 19, 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. The Plan denied your request. The Plan says IRF admission is not medically necessary.

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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for vertigo and pulmonary edema. Medical conditions are stable.

There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on December 3, 2020.

You asked the Plan to pay for the durable medical equipment. 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.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. 

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on December 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye surgery provided on January 14, 2021.

You asked the Plan to waive the copayment for the eye surgery. You say that you had issues with the skin on your upper eyelid which caused vision problems. You say you would like to appeal this claim. The Plan denied your request. The Plan says you have been asked to pay 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 $110 copayment for all other Ambulatory Surgical Center (ASC) services.

You have been asked to pay a $110 copayment for the eye surgery. The eye surgery 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 for the eye surgery provided on January 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the technical component of an abdominal x-ray, the transportation of portable x-ray equipment, and the set-up portable x-ray equipment.

You asked the Plan to pay for the technical component of an abdominal x-ray, the transportation of portable x-ray equipment, and the set-up portable x-ray equipment. You say that the records provided support the services in dispute. The Plan denied your request. The Plan says the services which remain in dispute are included in the SNF consolidated billing.

The Plan must follow Medicare rules. Medicare rules say that a SNF must submit all Medicare claims for all services that its residents received under Part A, except for certain excluded services. Medicare rules also say that technical components billed for services provided in a SNF must be billed by the SNF for its Part A inpatients and the Plan will pay only the professional component to the physician. 

We looked at the file and Medicare rules. The records show that the transportation of portable x-ray equipment and the set-up of portable x-ray equipment are not among the types of services which are excluded from consolidated billing. These services were provided to a SNF resident under Part A and are not paid separately to the provider. The technical component of the abdominal x-ray must also be billed by the SNF for its Part A inpatient resident. Based on this information, we decided that Medicare rules for coverage of the technical component of an abdominal x-ray, the transportation of portable x-ray equipment, and the set-up portable x-ray equipment have not been met. Therefore, we decided that the Plan does not have to pay for the technical component of an abdominal x-ray, the transportation of portable x-ray equipment, and the set-up portable x-ray equipment.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for surgery services provided on February 16, 2021.

You asked the Plan to reimburse you for repair initial inguinal hernia (49505) and repair umbilical hernia (49585). You say that the surgeon's office does not process insurance forms so you would like to be reimbursed for the procedures. The Plan denied your request. The Plan says this surgeon opted out of Medicare, so the services rendered are not eligible for reimbursement.

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 the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for surgery services provided on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 26, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 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 office visit provided on February 26, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for chiropractic services and outpatient rehabilitation services provided from October 20, 2020, to December 19, 2020.

You asked the Plan to waive the deductible for chiropractic services and outpatient rehabilitation services. You say that you thought that you were allowed to receive chiropractic services and do not understand why the Plan has not paid anything toward the claims. 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. Your contract with the Plan says that there is a $471 deductible for chiropractic services and outpatient rehabilitation services. 

You received chiropractic services and outpatient rehabilitation services from October 20, 2020, to December 19, 2020, for a total of 3 visits. The record shows that at the time services were received, you had not met the $471 deductible. Therefore, you are responsible to pay the total deductible amount of $212.94. 

The items or services you asked the Plan to waive the deductible for fall within the benefit categories: chiropractic services and outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $471 deductible for chiropractic services and outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time chiropractic services and outpatient rehabilitation services were received on October 20, 2020 to December 19, 2020. Therefore, we decided that the Plan does not have to waive the deductible for chiropractic services and outpatient rehabilitation services provided from October 20, 2020, to December 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on September 2, 2020.

You asked the Plan to pay for code 97110. 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. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that code 97110 is not supported in the medical record. Specifically, the records indicate that the services were performed by a physical therapist assistant in a home health or hospice setting. There is a more appropriate code for the billed services provided in a home health setting. Therefore, we decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on September 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the radiofrequency ablation of multiple levels (5) of the left lumbar spine (64635, 64636).

You asked the Plan to pre-approve the radiofrequency ablation of multiple levels. You say that the service is medically necessary. The Plan denied your request. The Plan says your request does not meet the criteria for medical necessity as outlined by Medicare rules as the enrollee had already exhausted their two sessions per spinal region within twelve rolling months.

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 radiofrequency ablation of multiple levels. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the request exceeds both utilization criteria in terms of sessions and levels. 

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 radiofrequency ablation of multiple levels have not been met. Specifically, your request exceeds the allowed sessions and levels. This means the service is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the radiofrequency ablation of multiple levels (5) of the left lumbar spine (64635, 64636).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on September 30, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage of all cardiovascular risk assessment panels, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

We looked at the file and the rules. In this case, there are insufficient medical records showing that the results of the testing would be used in the management of a specific medical problem. The testing services were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit provided on March 3, 2021.

You asked the Plan to pre-approve the office visit. You say that you were told you could get 10 visits in one year. The Plan denied your request. The Plan says routine chiropractic care is not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Office visits, when provided by a chiropractor, are not covered. Therefore, we decided that the Plan does not have to pre-approve the office visit provided on March 3, 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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 that the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 

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. Specifically, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided at a lower level of care, meaning admission to an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arterial puncture, withdrawal of blood for a diagnosis (36600) and the laboratory service (82803) provided on March 8, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 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 $40 copayment for lab services only when provided in an outpatient hospital facility. 

You have been asked to pay a $40 copayment for the laboratory services provided in an outpatient hospital facility. 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 arterial puncture, withdrawal of blood for a diagnosis (36600) and the laboratory service (82803) provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for thyroxine testing (84439) provided on January 8, 2021.

You asked the Plan to pay for thyroxine testing. You say that this should be covered. The Plan denied your request. The Plan says this exceeds MUE.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 84439 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of thyroxine testing have not been met. Therefore, we decided that the Plan does not have to pay for thyroxine testing (84439) provided on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory pathogen screening panel (87496, 87498, 87541, 87640, 87798) provided on January 18, 2021.

You asked the Plan to pay for a respiratory pathogen screening panel. You say that this should be covered. The Plan denied your request. The Plan says this was screening testing.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The testing at issue in this appeal, a respiratory pathogen screening panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a respiratory pathogen screening panel (87496, 87498, 87541, 87640, 87798) provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities provided on June 4, 2020.

You asked the Plan to pay for therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (97530). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is an appropriate code for the billed service in a home health or hospice setting.

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 Place of Service 12 is Home, therefore the CPT code is incorrect. Based on this information, we decided that Medicare rules for coverage of therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (97530) have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities provided on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 3, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 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 office visit provided on November 3, 2020 by an out of network (OON) provider.