Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to waive the copayment for the physical therapy (PT) and occupational therapy (OT) services provided as part of home health services (G0151, G0152) provided September 15, 2020, and September 16, 2020.

You asked the Plan to waive the copayment for the PT and OT services. You say that the PT and OT should be included as part of your home health services and should not have a separate copayment. The Plan denied your request. The Plan says that the Plan contract allows for separate copayments for PT and OT even though they were provided as a part of home health services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Plan contract states that there is no charge for Home Health services. It further states that covered services include physical therapy, occupational therapy, and speech therapy. The Plan contract does not clearly disclose how much enrollees should expect to pay for PT and OT when received as a part of home health services. 

We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $20 copayment for PT and OT when received as a part of home health services. The Plan contract does not clearly say how much enrollees must pay for PT and OT when received as a part of home health services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for the physical therapy (PT) and occupational therapy (OT) services provided as part of home health services (G0151, G0152) provided September 15, 2020, and September 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 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. The records show that the patient appears to still be unstable and requires additional short-term acute care services which can safely be provided in the current setting. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 6, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that you feel that this service should be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not elect to purchase the additional optional dental coverage.
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 pay for the periodontal maintenance (D4910) provided on October 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided May 12, 2020, to May 15, 2020.
You asked the Plan to pay for the inpatient services. You say that the Plan should pay the claim as DRG 377 The Plan denied your request. The Plan says based upon the Uniform Hospital Discharge Data Set (UHDDS) rules, the corrected DRG 378 G.I. HEMORRHAGE W CC is more appropriate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. In this case, you billed the services provided from May 12, 2020, to May 15, 2020 with DRG 377, J96.01. 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 the inpatient services. Our reviewer says that per the reviewed documentation, the clinical documentation did not support that the following diagnosis impacted this hospital admission-J96.01 acute respiratory failure with hypoxia. Our physician reviewer found the enrollee had underlying COPD, a large pleural effusion, and mild hypoxia. There was no respiratory distress. The mild hypoxemia could be explained by the COPD, effusion, and reduced oxygen carrying capacity with the severe anemia. There was no clinical evidence of acute respiratory failure. The review has determined that the corrected DRG 378 G.I. HEMORRHAGE W CC is appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG 377, J96.01. Therefore, we decided that the Plan does not have to pay for inpatient services provided May 12, 2020, to May 15, 2020 at the DRG 377 rate.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services provided on June 20, 2020.
You asked the Plan to pay for the transportation services. The Plan denied your request. The Plan says the service is not covered under the enrollee's plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the transportation services provided on June 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (K0861) and accessories (E1007, E0955, E1028, E2377, E2313, E2311, E2607 E1012, K0108, K0040, E2300, E2613, E2359).
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options and accessories. You say that the enrollee meets the criteria for coverage of the requested wheelchair. The Plan denied your request. The Plan says the specific wheelchair requested is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power options will be covered if the beneficiary either meets coverage criteria for a power tilt and recline seating system and the system is being used on the wheelchair or uses a ventilator which is mounted on the wheelchair. 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 a group 3 power wheelchair with multiple power options and accessories. Our reviewer says that the enrollee does not meet the criteria for the requested group 3 power wheelchair with multiple power options as the patient does not meet the coverage criteria for the multiple power options. Our physician reviewer found the enrollee does not require a power tilt and recline seating system. He is not at high risk for development of a pressure ulcer and he is able to perform a functional weight shift as he can still ambulate. The enrollee does not utilize intermittent catheterization for bladder management. He does not use a ventilator. The power seating system is not needed to manage increased tone or spasticity. As the requested power wheelchair is not medically necessary, the requested
accessories are also not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 3 power wheelchair with multiple power options and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (K0861) and accessories (E1007, E0955, E1028, E2377, E2313, E2311, E2607 E1012, K0108, K0040, E2300, E2613, E2359).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wound care products identified with code A6250 and A6260.
You asked the Plan to pre-approve the requested items. You say that your wound needs to be cleaned 3 times a day. The Plan denied your request. The Plan says the requested items are non-covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6250 and A6260 are non-covered because they do not meet the statutory definition of a surgical dressing. The file shows that skin sealants (A6250), and wound cleansers (A6260) are non-covered. Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve wound care products identified with code A6250 and A6260.
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 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 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 that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear medicine full body scan or the CT scan provided on August 21, 2020. You asked the Plan to waive the copayment for the nuclear medicine full body scan and the CT scan. You say that the claim should be paid because you were not aware the provider was no in-network. 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 $225 copayment for all other diagnostic and nuclear medicine radiological services. You have been asked to pay a $225 copayment for the nuclear medicine full body scan and a $225 copayment for the CT scan. The nuclear medicine full body scan and the CT scan fall within "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the provider was in-network. 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 nuclear medicine full body scan or the CT scan provided on August 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from September 4, 2020, to September 30, 2020.
You asked the Plan to waive the copayment for the SNF stay. You say that you were not told that after 20 days there would be a copayment. 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 $0 copayment per day, days 1 to 20 at an in-network skilled nursing facility and a $160 copayment per day, days 21 to 100 at an in-network skilled nursing facility. You have been asked to pay a $1,120 copayment for the SNF stay. The SNF stay falls within "Skilled nursing facility (SNF) care" benefit category. See chart below.
Dates of Service
Service
Copayment per Day
SNF Days
Number of Days
Member Liability
September 4, 2020 to September 23, 2020
SNF care
$0
1-20
20
$0
September 24, 2020 to September 30, 2020
SNF care
$160
21-27
7
$1,120
Total
$1,120
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 SNF stay provided from September 4, 2020, to September 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nasal endoscopies provided on September 9, 2020 and September 23, 2020.

You asked the Plan to waive the copayment for nasal endoscopies. You say that these were provided as follow-up after surgery and should be included in the global period for the surgical procedure. The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $150 copayment for each nasal endoscopy. For each endoscopy, you have been asked to pay the allowed amount of $145.16, which is less than the $150 copayment. There were 2 endoscopies, resulting in a total copayment obligation of $290.32. 

You have been asked to pay less than $150 copayment for each nasal endoscopy. Nasal endoscopies fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 nasal endoscopies provided on September 9, 2020 and September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 8, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says it cannot be determined whether the services were medically necessary.

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 billed services are not supported in the medical record. In this case, there is insufficient medical records to substantiate the billed services. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that these services were provided in good faith. The Plan denied your request. The Plan says the referring provider is not in-network. The Plan says that prior authorization was not 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 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 lab work provided on November 10, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel provided to the enrollee on September 11, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this should be reported with a single code - CPT 81479.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel provided to the enrollee on September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this will keep your foot straight. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on May 25 to May 29, 2020.

You asked the Plan to pay for physical therapy. You say that the requested care was necessary. The Plan denied your request. The Plan says rules for payment have not been met.

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 pay for physical therapy. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee was at a functional level on May 25, 2020, that did not require the unique skills of a professional therapist to safely and effectively provide treatment, or have services be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge, and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on May 25 to May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia for dental services.
You asked the Plan to pre-approve the servcies. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered 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 deep sedation/general anesthesia for dental services.
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 transfer to a long-term acute care facility is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met.

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 records show you were admitted to the current acute care facility for planned right hemicolectomy due to ischemia. You underwent the colon resection and required bicarb, antibiotics, vasopressors, dialysis, and later intubation due to sepsis. You were diagnosed with metabolic encephalopathy. You appear to be stable and your care can be provided in the current hospital setting. You do not require services that are not already available at the current facility. Medicare coverage criteria for transfer are not met. 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.