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

We decided that the Plan has to pay for the acute inpatient hospital care provided June 2, 2019 to June 5, 2019.
You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient hospital care provided was medically necessary. The Plan denied your request. The Plan says that the inpatient hospital care provided was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that on June 2, 2019 the enrollee presented to the Emergency Department (ED) complaining of increasing dyspnea and edema in his legs. The enrollee had run out of oxygen a few days prior to this admission and was found to be hypoxic. On June 3, 2019 after treatment with intravenous diuretics, the enrollee denied being short of breath and hypoxia resolved. On June 5, 2019 he was then discharged home. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided June 2, 2019 to June 5, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for static progressive stretch knee device (E1811) provided September 13, 2019.You asked the Plan to pay for static progressive stretch knee device. You say that verification of benefits was obtained and Medicare requirements were met for medical necessity and you request immediate payment.The Plan denied your request. The Plan says this service is not a covered benefit.The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery.You have not had total knee replacement surgery.Therefore, we decided that the Plan does not have to pay for static progressive stretch knee device (E1811) provided September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet injections (64493)
You asked the Plan to pre-approve the injections. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the injections 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 the injections. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation does not indicate there has been at least 3 months of moderate to severe pain
with functional impairment inadequately responsive to conservative care. The documentation is not clear that
the member's symptoms are purely axial. There is no objective documentation such as a lumbar imaging study
that reveals there is absence of non-facet pathology that could explain the source of the patient's pain, such as
fracture, tumor, infection, or significant deformity. The clinical assessment is not supportive that the facet joint
is the putative source of pain.
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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve lumbar facet injections (64493)
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for CPT 95861. We decided that the Plan does not have to pay for CPT 95937.
You asked the Plan to pay for the denied codes. You say that this should be paid for. The Plan says that the clinical information submitted does not provide evidence that monitoring occurred within the hospital setting. We decided that the Plan has to pay for CPT 95861. 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 95861 is "Needle electromyography." 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 for CPT 95861. Our reviewer says that the records support this code. Our physician reviewer found that CPT 95861 should be paid. The documentation supports the performance of needle EMGs on two extremities. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 95861 have been met. Therefore, we decided that the Plan has to pay for CPT 95861. We also decided that the Plan does not have to pay for CPT 95937. 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 95937 is "Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method." 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 for CPT 95937. Our reviewer says that the records do not support this code. Our physician reviewer found that CPT 95937 should be denied. The documentation does not support the performance of neuromuscular junction testing. Train of Four monitoring is not considered neuromuscular junction testing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 95937 have not been met. Therefore, we decided that the Plan does not have to pay for CPT 95937.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vehicle power mobility device lift.
You asked the Plan to pre-approve a scooter car lift. You say that the enrollee needs the scooter car lift to transport the scooter. The Plan denied your request. The Plan says scooter car lifts are medical equipment and not covered by Medicare or the Plan.
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. Also, 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. Therefore, we decided that the Plan does not have to pre-approve a vehicle power mobility device lift.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe transarterial chemoemolization procedure. You say that you would like reconsideration as treatment has been delayed due to insurance issues. The Plan denied your request. The Plan says your benefit package requires the use of in-network providers unless the situation is urgent or emergent.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95910) provided on October 16, 2019.
You asked the Plan to pay for the nerve conduction studies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted documentation does not indicate that nerve conduction studies; 7-8 studies were performed.
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 95910 is nerve conduction studies; 7-8 studies . We asked our coder 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 nerve conduction studies. Our reviewer says that CPT code 95910 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation to corroborate that nerve conduction studies; 7-8 studies, were performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95910) provided on October 16, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from February 17, 2019 to March 7, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claims are being submitted with inappropriate home health data to process and pay claims.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the final claim includes a HIPPS Code which indicates non-routine supplies were provided. There are no supply charges listed on the claim. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 17, 2019 to March 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2751) for teeth # 6 and 11, prefabricated post and core in addition to a crown (D2954) for teeth # 6 and 11, root canals (D3310) for teeth # 6 and 11, and the periodontal scaling and root planing (D4341) for all 4 quadrants.You asked the Plan to pre-approve the dental services. You say that you recently had cancer. You say that you had to get cancer surveillance and need to have the services completed.The Plan denied your request. The Plan says crowns and prefabricated post and core in addition to a crown are not covered services. The Plan says medical necessity cannot be determined for the root canals and periodontal scaling and root planing for all 4 quadrants due to not receiving any x-rays or documentation for review.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, crowns, and post and core in addition to crowns are not among those covered under this benefit. Additionally, the root canals and periodontal scaling and root planning cannot be determined medically necessary without documentation being provided. The records show that the Plan requested medical records and none were received from the provider.Therefore, we decided that the Plan does not have to pre-approve crowns (D2751) for teeth # 6 and 11, prefabricated post and core in addition to a crown (D2954) for teeth # 6 and 11, root canals (D3310) for teeth # 6 and 11, and the periodontal scaling and root planing (D4341) for all 4 quadrants
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services from October 31, 2019 through November 2, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share responsibility for the services you received. 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). The Outpatient Hospital Services including the Diagnostic Chest X-ray, the CT Scan and the Echocardiology provided on October 31, 2019 through November 2, 2019 were processed correctly. According to pages 74 and 75 of your 2019 EOC, you are responsible for a $290 copayment for Basic Radiological Services which involves CPT Code 93306 for the Echocardiology. Similarly, a $250 copayment for Advanced Imaging Services which involves CPT Code 71046 for the Chest XRAY and CPT Code 74178 for the CT Scan General at an Outpatient Hospital. Therefore, the claim processed correctly and paid according to your in-network benefits so we are upholding our original decision. Had you been admitted to the hospital for those two days your member responsibility would be $790 per your EOC pages 70 and 71 for Inpatient Hospital Care. 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 services from October 31, 2019 through November 2, 2019 provided by an in-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an esophageal x-ray (74220) provided on September 6, 2019.
You asked the Plan to pay for the esophageal x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted documentation supports 1 unit of 74420-26, which was previously approved and paid.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the esophageal x-ray have not been met. Specifically, the record indicates that a claim for CPT code 74220 has been processed and paid. The record does not indicate that this service was rendered more than once on this date of service. Therefore, we decided that the Plan does not have to pay for an esophageal x-ray (74220) provided on September 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cervical/Thoracic Interlaminar Epidural for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that they did not receive documentation that this is medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 reviewer says that the epidural is not medically reasonable and necessary for the enrollee in this case. The enrollee has cervicalgia and documented cervical stenosis. The most recent submitted office note dated 3/2/2020 states that the prescriber was increasing the enrollee's Duloxetine from 30 mg orally to 60 mg orally. As well, the note states that a referral for home physical therapy/occupational therapy was placed and is "pending." There is no documentation that there has been any physical therapy, for the enrollee's neck. Based upon the submitted records there is no documentation that the enrollee has tried and failed conservative therapy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a Cervical/Thoracic Interlaminar Epidural for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for psychotherapy provided from August 30, 2019 to November 8, 2019.
You asked the Plan to waive the coinsurance for psychotherapy. You say that the provider is in-network and
you unhappy with the billing issues. 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for out-of-network outpatient mental health care.
You received psychotherapy from an out-of-network provider from August 30, 2019 to November 8, 2019 for a
total of 8 visits. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges.
The allowed amount is $136.24 and 20% of that is $27.24. The total amount you owe is: $27.24 (coinsurance)
x 8 (visits) = $217.92.
You have been asked to pay the total coinsurance amount of $217.92 for psychotherapy. Psychotherapy falls
within the outpatient mental health 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 coinsurance
for psychotherapy provided, from August 30, 2019 to November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the office visit (99214). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 28, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the rehab needs are not complex, and do not require an interdisciplinary approach.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR, HHS, LTC/ECF).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 Plandoes not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.