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

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 20, 2019 through December 26, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were ready to go to skilled nursing facility rehabilitation, however, authorization was not received from insurance. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on December 20, 2019 and discharged on December 26, 2019. You should have been asked to pay a $370 copayment per day, but the Plan charged you a $360 copayment per day from December 20, 2019 through December 24, 2019, days 1-5 of your inpatient stay. There were no copayment charges from December 25, 2019, day 6 of your inpatient hospital care until your day of discharge December 26, 2019. Per your contract there is a $370 copayment per day required for days 1-5. Therefore, you are being charged the lesser amount. 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 inpatient hospital care from December 20, 2019 through December 26, 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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 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 you required moderate assistance with mobility and activities of daily living. You are generally medically stable with thoracic vertebral fractures, status post surgical fixation with no acute medical events. There is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or need for acute rehab nursing care. While you may benefit from further physical therapy and occupational therapy, you do not require an intensive 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 1, 2019 to May 8, 2019 by provider.You asked the Plan to pay for SNF care. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says prior authorization was not requested or received for the services, therefore coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that plans may require enrollees to obtain authorization before receiving services.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pay forskilled nursing facility (SNF) care provided from May 1, 2019 to May 8, 2019 by provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea high frequency chest wall oscillation device (HFCWOD) for the enrollee.You asked the Plan to pre-approvea HFCWOD. You say that this is medically necessary.The Plan denied your request. The Plan says that the member's documented diagnosis of severe persistent asthma is not a diagnosis included in Medicare's medical necessity criteria.The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. We asked our physician reviewer to carefully reviewthe case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a HFCWOD. Our reviewer says that a HFCWOD is not medically reasonable and necessary for the enrollee. The enrollee does not havecystic fibrosis, bronchiectasis, or a neuromuscular disease. The provided medical records do not document that the enrollee presently uses a mechanical in-exsufflation device. The provided medical records do not document failure of standard treatments to adequately mobilize retained secretions. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a HFCWOD.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 HFCWOD have not been met.Therefore, we decided that the Plan does not have to pre-approvea high frequency chest wall oscillation device (HFCWOD) for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four bone replacement grafts (D4263).You asked the Plan to pre-approve the bone replacement grafts. You say that this service is medically necessary. You also say that you do not have the money to pay for this procedure yourself.The Plan denied your request. The Plan says this service 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 four bone replacement grafts (D4263).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision services provided to the enrollee on November 1, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the records do not indicate the billed services were provided. Code 11622 would be more appropriate. 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 11626 is excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm. 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 services provided. Our reviewer found that the medical records provided do not include documentation of an excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm. Therefore, this service cannot be validated. 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 services provided have not been met. Therefore, we decided that the Plan does not have to pay for the excision services provided to the enrollee on November 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from September 16, 2019 through September 23, 2019. You asked the Plan to pay for inpatient mental health care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary. 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 pay for inpatient mental health care. Our physician reviewer found based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 16, 2019 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 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 mental health care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from September 16, 2019 through September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay fororthopedic services (CPT 22845) provided to the enrollee on November 4, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plansaysthe denied code is not supported in the medical records submitted.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 22845 is "anterior instrumentation for 2 to 3 vertebral segments (listed separately in addition to code for primary procedure)."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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the medical records provided do not include documentation of an anterior instrumentation for 2 to 3 vertebral segments (listed separately in addition to code for primary procedure. This description is not documented in the operative report, therefore 22845 cannot be verified.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 services have not been met.Therefore, we decided that the Plan does not have to pay fo rorthopedic services (CPT 22845) provided to the enrollee on November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental surgery provided October 8, 2019.You asked the Plan to pay forthe dental services. You say that you did not know you needed prior approval for this procedure. You have been retired for several years and now working a part time job to try to pay for this huge bill and you request reimbursement.The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider. The plan says that non-emergent services with non-contracted providers requireprior-authorization prior to services being rendered.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. The healthplan contract says that dental services rendered by an out-of-network dental provider is not covered by the plan.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 forthe dental surgery provided October 8, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve placement of a CardioMEMS heart failure monitor.
You asked the Plan to pre-approve the CardioMEMS device. You say that there is evidence that this treatment would be beneficial for this patient who has not been able to stabilize under un-monitored heart failure treatments. The Plan denied your request. The Plan says that this is not covered by Medicare as it is considered experimental at this time.
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 the CardioMEMS device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the patient has heart failure with preserved ejection fraction and is on a good medical regimen with control of blood pressure. She has had a number of recent admissions for severe congestive heart failure. In this situation, a CardioMEMS PA pressure monitoring device has been shown to reduce recurrent hospitalizations when used with close monitoring in order to closely titrate diuretic therapy based on PA pressures. As the patient has already failed a trial of unmonitored treatment (in a rehab facility) it is likely she will have further readmissions for CHF when discharged home. The Champions trial (including a pre-specified subgroup study of patients with Class III heart failure and preserved ejection fraction) showed a significant reduction in hospital readmissions in patients monitored and treated based on information provided by the CardioMEMS device to their care providers. In this specific clinical instance the CardioMEMS device is therefore appropriate and medically necessary, and there is randomized published data to support its use. 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 CardioMEMS device have been met. Therefore, we decided that the Plan has to pre-approve placement of a CardioMEMS heart failure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forend stage renal disease (ESRD) services provided to the enrollee from February 1, 2019 to February 27, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare guidance says Effective January 1, 2012, ESRD facilities are required to report hematocrit or hemoglobin levels on all ESRD claims. Reporting the value 99.99 is not permitted when billing for an ESA.The revenue codes for reporting Epoetin Alfa are 0634 and 0635. All other ESAs are reported using revenue code 0636. The HCPCS code for the ESA must be included: HCPCS -Q4081; HCPCS Description -Injection, Epoetin alfa, 100 units (for ESRD on Dialysis); Dates of Service -1/1/2007 to present.Each administration of an ESA is reported on a separate line item with the units reported used as a multiplier by the dosage description in the HCPCS to arrive at the dosage per administration. As the HCPCS code Q4081 was billed without modifier JA, JB or JE; the Medicare rule for payment of this claim has not been met. 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 claim submitted cannot be paid as billed due to a modifier error. The Plan states a corrected claim would be reviewed if submitted. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forend stage renal disease (ESRD) services provided to the enrollee from February 1, 2019 to February 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar decompression for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show progressive nerve deficit.
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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the MRI does not show evidence of severe spinal stenosis, or root compression from disc herniation. The surgery is not indicated. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar decompression for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network mental health care provided to the enrollee from October 24, 2019 to November 21, 2019. You asked the Plan to pay for out of network providers. You say that these visits should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 out of network mental health care provided to the enrollee from October 24, 2019 to November 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveright carpal tunnel surgery with ulnar release for the enrollee. You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no description of the enrollee's right upper extremity symptoms or functional impairment. There is no documentation of a right upper extremity clinical exam documenting positive provocative testing or sensory deficits consistent with right carpal tunnel and cubital tunnel syndrome. There is no documentation of positive electrodiagnostictesting. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has not been submitted. In the absence of this information, the medical necessity of this request cannot be established consistent with evidence based medical literature. Therefore, the surgical request for right carpal tunnel surgery with ulnar release would not be considered the standard of care or medically reasonable and necessary for treatment of the enrollee's medical condition at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveright carpal tunnel surgery with ulnar release for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to approve eight further physical therapy (PT) visits for enrollee.You asked the Plan to approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says six visits are approved but eight further 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 approve these services. 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 enrollee had a total shoulder replacement on October 1, 2019 and has been receiving PT before and after surgery for a total of 50 visits since June of 2019. The limited records contain only one clinical note. The records do not indicate the skills of a therapist are necessary. There is a lack of documentation regarding whether the enrollee was given a home exercise program to maintain or improve the range of motion of his shoulder. The enrollee does not require the the eight further visits to design and/or deliver a program to maintain his 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 these services have not been met.Therefore, we decided that the Plan does not have to approve eight further physical therapy (PT) visits for enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forintermittent limb compression device.You asked the Plan to pay forintermittent limb compression device. You say that the enrollee had hand surgery and this device was needed during and after surgery to lessen the chances of blood pooling and clotting in their legs.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.The file does not show that enrollee has lymphedema and/ or chronic venousinsufficiency with venous stasis ulcers.Therefore, we decided that the Plan does not have to pay forintermittent limb compression device.