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

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 hematuria and massive bladder clot after recent TURP. Hospital complications included new on set atrial fibrillation, pulmonary embolism and respiratory arrest. Medical problems 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, in 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.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute care facility. There are no servicesavailable at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The hospital has approved ongoing care in the current acute care facility. The requested LTACH services are not medicallynecessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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-approvelong term acute care hospital (LTACH) services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you are requesting reconsideration of the preauthorization denial for IRF admission after having hip surgery.The Plan denied your request. The Plan says the stay 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 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 surgical repair of a hip fracture after a fall. 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-approveacute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthetic injection (64415) provided .

You asked the Plan to pay for the anesthetic injection. You say that you would like reconsideration because you have no control over any requirements placed by the surgeon. The Plan denied your request. The Plan says it is not appropriate to report unspecified, or left and right diagnosis codes when the procedure modifier on the claim line does not match the diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code 64415 is not supported in the record. Specifically, CPT code 64415 was billed with the RT modifier to specify the right side, but the diagnosis code billed on the claim indicates the left side. Based on this information, we decided that Medicare rules for coverage of the anesthetic injection have not been met. Therefore, we decided that the Plan does not have to pay for the anesthetic injection (64415) provided
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea dental extraction (D7210).You asked the Plan to pre-approvea dental extraction. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says x-rays are needed to decide if this service is medically necessary.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 at this time. The Plan requires dental x-rays in order to determine medical necessity. The Plan made multiple attempts for dental x-rays; however, none were provided.Therefore, we decided that the Plan does not have to pre-approvea dental extraction (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital clinic visit provided .

You asked the Plan to pay for the hospital clinic visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 hospital clinic visit. 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 hospital clinic visit provided
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pay foradditional reimbursement for services received.You asked the Planto pay forthe services. You say that you have been inadequately reimbursed for these services.The Plandenied your request. The Plansaysthe 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 the provider who has opted out of the Medicare program.Therefore, we decided that the Plandoes not haveto pay foradditional reimbursement for services received.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forTetanus vaccine (CPT code 90715) provided You asked the Plan to pay forthe Tetanus vaccine. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the submitted claim shows that you received this as a preventative measure, which means that the tetanus vaccination is not covered under your medical plan. The Plan states in order for your tetanus shot to be covered, you must first pay up front and file for reimbursementthrough your Part D plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus vaccine. The Plan follows the same rules. Coverage for a tetanus vaccination is covered under Medicare Part B if it is related to an accidental puncture woundor injury. The Plan states the submitted claim shows that you received this as a preventative measure, which means that the tetanus vaccination is not covered under your medical plan.Therefore, we decided that the Plan does not have to pay forTetanus vaccine (CPT code 90715) provided .Benefits for the Tetanus vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approveright knee arthroscopy for the enrollee.You asked the Plan to pre-approvethese services. You say that these services are medically necessary.The Plan denied your request. The Plan says that that the medical records received does not support the medical necessity of the requested service.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 these services. Our reviewersays that the requested services are considered medically reasonable and necessary in this case. The enrollee is being treated for unilateral primary osteoarthritis of the right knee, complex tear of lateral meniscus, current injury, right knee. The  treating physician report cites continued right knee pain. She is walking with an antalgic gait and has moderate to severe pain. The knee intermittently clicks and gives out. Exam reveals right knee periarticular swelling with mild effusion. Range of motion is from 10-90. There is a positive McMurray's. Lateral joint line tenderness is noted. There is crepitance with range of motion. MRI demonstrated grade 1 MCL injury; probable lateral meniscus tear; focal cartilage defect along medial femoral condyle; mild soft tissue edema. There is documentation of knee giving way with objective findings of swelling, effusion, lateral joint line tenderness, as well as positive McMurray's. Medications, injections, and restricted activities have also been tried and failed. Our physician reviewer found that the enrollee's condition meets Medicare criteria for these services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pre-approveright knee arthroscopy for the enrollee.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 toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forpneumatic compressor (E0650) and segmental gradient pressure pneumatic appliance (E0673) provided .You asked the Plan to pay forpneumatic compressor and segmental gradient pressure pneumatic appliance. You say that the items are medically necessary.The Plan denied your request. The Plan says the DME must be for use in the patient's residence other than a healthcare institution and payment cannot be made for equipment for use in an institution.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Specifically, the items were requested for use in anambulatory surgical center and cannot be approved for this location.Therefore, we decided that the Plan does not have to pay forpneumatic compressor (E0650) and segmental gradient pressure pneumatic appliance (E0673) provided
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee 

You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this was not coded correctly.

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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.The Plan must follow Medicare rules. The rules say that an 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 consideredmedically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems are stable. You do not have 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.Additionally, thereis 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-approvean acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe chair portion of a lift seat.You asked the Planto pre-approvethe chair. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is an excluded benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plandoes not haveto pre-approvethe chair portion of a lift seat.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cryopreservation; embryo(s) and Complete in vitro fertilization cycle.

You asked the Plan to pre-approve Cryopreservation; embryo(s) (89258) and Complete in vitro fertilization cycle (S4015). You say that the enrollee needs these procedures. The Plan denied your request. The Plan says infertility coverage is limited to procedures that are medically necessary to diagnose and treat correctable medical conditions.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. Neither Medicare nor the Plan covers the requested infertility services. S codes are unique temporary codes established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy management have not been met. Based on this information, we decided that Medicare rules for coverage of Cryopreservation; embryo(s) (89258) and Complete in vitro fertilization cycle (S4015) have not been met. Therefore, we decided that the Plan does not have to pre-approve Cryopreservation; embryo(s) and Complete in vitro fertilization cycle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea standing frame/table system, multi position for the enrollee.You asked the Planto pre-approvethe item. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested item does not meet the requirements to be considered DME.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plandoes not haveto pre-approvea standing frame/table system, multi position for the enrollee
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided .You asked the Plan to waive the copayment forthe emergency room visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received emergency care services on the date of service at issue in this appeal. The Plan says that the correct copayment hasapplied per your contract with the Plan.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 mustpay a $120 copayment for Emergency care. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room services. You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the Emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe emergency room visit provided
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe X-rays of the right and left foot and office visit with a podiatrist (73630, 99203) provided February 24, 2020.You asked the Plan to waive the copayments forthe X-rays and office visit. You say that you did not want the X-rays and donotagree with the copayments.The Plan denied your request. The Plan says the copayments were applied correctly.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 most X-rays and ultrasounds. The Plan contract also says that you pay a $35 copayment per visit for Medicare-covered podiatry services.You have been asked to pay a total of $75 (($20 copayment x 2 X-rays) + $35 copayment for office visit = $75) for the X-rays and office visit. The X-rays fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit categoryand theoffice visitwith a podiatrist falls within the Podiatry 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 copayments forthe X-rays of the right and left foot and office visit with a podiatrist (73630, 99203) provided February 24, 2020.