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

We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on October 21, 2020.
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99291.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress note for October 21, 2020 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan provided on October 13, 2020 by an out of network provider.
You asked the Plan to pay for duplex scan of extracranial arteries; complete bilateral study (93880). You say that the provider should not be penalized because the hospital did not obtain authorization. The Plan denied your request. The Plan says you did not request prior authorization for the out of network procedure.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the duplex scan provided on October 13, 2020 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care will be medically necessary following the enrollee's surgery. The Plan denied your request. The Plan says the criteria for inpatient coverage have not been met.
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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is a 67-year-old female who has been approved for an elective total right hip arthroplasty. The review has determined that the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed on the Centers for Medicare & Medicaid Services Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review indicates that the record does not show 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is covered by Medicare. The Plan denied your request. The Plan says this is experimental.
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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex procedure remains experimental for low back pain. More research is needed to show the safety and efficacy of the device. 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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care provided from September 22, 2020, to September 28, 2020.
You asked the Plan to pay for subsequent hospital care. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the medical records are incomplete for the subsequent hospital visit claim.
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 99232 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. The definition of code 99233 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99232 and 99233 is not supported in the medical record. Specifically, there are no notes for several of the dates of service, submitted notes are illegible and time spent was not recorded. Based on this information, we decided that Medicare rules for coverage of subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay the claim for subsequent hospital care provided from September 22, 2020, to September 28, 2020.
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 IRF care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the patient was admitted for a stroke and aspiration pneumonia. Medical conditions are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 7, 2020 by an out of
network (OON) provider.

You asked the Plan to pay for an office visit. You say that you were told that this provider was in-network. The
Plan denied your request. The Plan says the rendering physician is out-of-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 an office visit provided on December 7, 2020 by an out of network (OON) provider.

We note your complaint about being told that this provider was in-network. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
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 enrollee will benefit from acute inpatient rehab that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the enrollee's medical and therapy needs can safely be met in another setting
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 there are no complex nursing or rehabilitation needs. The patient does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration treatment provided on June 10, 2020.
You asked the Plan to pay for the guided tissue regeneration. You say that you feel that this should be covered as a medical service as you had bone loss after an extraction that was causing a hole in your sinus. The Plan denied your request. The Plan says the provider you used is not Medicare-certified.
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. Although this treatment was provided prior to treatment of a sinus perforation, it is considered dental in nature as it was done to speed healing of structures directly supporting the teeth. This is not among the dental services for which your Plan offers coverage. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration treatment provided on June 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary for the enrollee's condition as Xgeva is not an option due to established treatment. The Plan denied your request. The Plan says Prolia is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Prolia. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found in this case, the enrollee is a 68 year old man with metastatic hormone sensitive prostate cancer with extensive bone metastases. Prolia is not FDA approved for the enrollee's condition. In addition, the use of Prolia for the enrollee's condition is also not supported by relevant Medicare approved compendia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on December 8, 2020.
You asked the Plan to pay for the services. You say that this should be covered based on Medicare guidelines. The Plan denied your request. The Plan says this not covered except for pregnant patients.
The Plan must follow Medicare rules. Medicare rules say that MTHFR testing is only covered for pregnant patients. The enrollee does not qualify for this testing. 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 genetic testing services provided to the enrollee on December 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance transportation services (A0429HH, A0425HH) provided on July 10, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee required round trip transportation from their nursing home to a treatment center and back to the nursing home. You say that the first trip was covered, so this second trip should be covered as well. The Plan denied your request. The Plan says there is not sufficient information to approve these services.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.
Based on the documentation submitted, we cannot review whether these services are medically necessary or emergent. There also appears to be a discrepancy between where you say the enrollee was transported to/from and the codes billed. There is no documentation available to support either claim. Providers are required to submit necessary information to the Plan when requested. We looked at the file and Medicare rules. Based on this information, we decided that we cannot determine if Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transportation services (A0429HH, A0425HH) provided on July 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an oral surgeon.
You asked the Plan to pre-approve the referral. You say that you have an infection that can set in within 30 days. The Plan denied your request. The Plan says an oral surgeon is not covered, per the Evidence of 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. Dental services must be provided by a participating general dentist. The requested provider is not covered by the plan's dental contract. Based on this information, we decided that the Plan's rules for coverage of the referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral to an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent limb compression device.
You asked the Plan to pre-approve the device. You say that this is medically necessary to prevent
complications. The Plan denied your request. The Plan says this is considered a preventive service.
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 the enrollee has lymphedema and/ or chronic venous insufficiency with venous
stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve an intermittent limb
compression device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient services provided from December 29, 2020, to January 4, 2021.
You asked the Plan to waive the copayment for the inpatient services. You say that would like the Plan to waive the copayment. Plan denied your request. The Plan says you were charged the copayment 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 $285 copayment per day for days 1-7 for Inpatient Hospital Care. You have been asked to pay a $285 copayment per day for days 1-7 for the inpatient services. The inpatient services fall within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient services provided from December 29, 2020, to January 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not require coordinated care between therapy disciplines.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for a total knee replacement and was discharged home with home health physical therapy.
There is ongoing pain and difficulty with ambulation. Her medical conditions are stable. There are no complex nursing needs. She does not require treatment by multiple therapies in an intensive rehabilitation therapy program. She does require physical and occupational therapy but there is no documented need for an intensive rehabilitation 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.