Persius/hicric huggingface dataset:
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the physical therapist recommended therapy for acute rehab to regain maximum function and that the member is not safe to return home at this time. The Plan denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for respiratory failure and coronavirus pneumonia. The enrollee's medical problems 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services provided on February 28, 2021 by an out-of-network provider.

You asked the Plan to pay for end-stage renal disease service (90960). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization and the place of service is incorrect on the claim.

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. The claim was submitted with a non-covered place of service of 02. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for telehealth services provided on February 28, 2021 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the clinic visits and lab services you received from an out-of-network outpatient hospital system from September 9, 2019, to November 20, 2019.

You asked the Plan to waive the coinsurance for the clinic visits and lab services. You say that you believe this bill should be paid by your insurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 50% coinsurance for services at an out-of-network outpatient hospital facility. 

You have been asked to pay 50% coinsurance for the clinic visits and lab services. The clinic visits and lab services falls within the services at an out-of-network outpatient hospital facility 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 the clinic visits and lab services you received from an out-of-network outpatient hospital system from September 9, 2019, to November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833) and a suspension sleeve (L2397) purchased on January 11, 2021.

You asked the Plan to pay for a knee brace and a suspension sleeve. You say that you have never heard of the supplier nor have you received any medical supplies or equipment. The Plan denied your request. The Plan says rules for payment for durable medical equipment have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for a knee brace (L1833) and a suspension sleeve (L2397) purchased on January 11, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the deductible for the initial nursing facility care, per day (99306) and the subsequent nursing facility care, per day (99309) provided on December 11, 2020 and December 17, 2020.

You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the deductible has been applied correctly to the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that an enrollee's deductible amount for the calendar year is $1,000. The deductible does not pertain to certain covered in-network services. 

The Plan says you must pay a $245.28 deductible for the nursing facility care provided as you had not previously met the Plan deductible for the calendar year. Based on the Plan contract, however, you cannot be asked to pay more than a $0 deductible for in-network physician/practitioner services provided. Therefore, we decided that the Plan has to waive the deductible for the initial nursing facility care, per day (99306) and the subsequent nursing facility care, per day (99309) provided on December 11, 2020 and December 17, 2020.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided on January 13, 2021 by a non-participating
provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-participating provider without prior authorization.

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 the x-ray provided on January 13, 2021 by a non-participating
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the hand (73130), x-ray exam of the
cervical spine (72040), routine venipuncture (36415), laboratory services (80053, 86140, 86706, 86803, 86704,
85025, 85652, 87340), and the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON)
provider on March 29, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the x-ray exam of the hand (73130), x-ray exam of the cervical spine (72040),
routine venipuncture (36415), laboratory services (80053, 86140, 86706, 86803, 86704, 85025, 85652, 87340),
and the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on March 29,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the doctor visits you had on October 29, 2020, and November 12, 2020.

You asked the Plan to waive the copayments for the doctor visits. You say that the clinic told you that copayments were waived for 2020. The Plan denied your request. The Plan says you were charged these copayments 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 $10 copayment for physician visits. 

You have been asked to pay a $10 copayment for the doctor visits. There is no provision in your Evidence of Coverage for a waiver of these amounts. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the doctor visits you had on October 29, 2020, and November 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there are no daily skilled nursing needs.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee requires skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit with a urologist you had on February 15, 2021.

You asked the Plan to waive the copayment for the urology visit. You say that you did not know that you had a copayment for this service. The Plan denied your request. The Plan says you were charged this 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 $10 copayment for visits with a specialist. 

You have been asked to pay a $10 copayment for the urology visit. The urology visit falls within the visits with a specialist 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 visit with a urologist you had on February 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services provided on January 6, 2021, by a PT assistant (PTA).

You asked the Plan to pay for the PTA services. You say that these services are medically necessary and billed correctly. The Plan denied your request. The Plan says there is a more appropriate code to report these services.

The Plan must follow Medicare rules. Medicare rules say that the services of a PTA cannot be billed incident to the services of a physician or NPP.

The billing physician is an NPP. PTA services are not payable unless billed by a supervising therapist. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided on January 6, 2021, by a PT assistant (PTA).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (20525) provided on October 15, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.

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 20525 is "Removal of foreign body in muscle or tendon sheath; deep or complicated."

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 services. Our reviewer says that the use of code 20525 is not supported by the records provided. Our reviewer found that the operative report does not include documentation to confirm a deep or complicated foreign body was removed from muscle or tendon sheath. Therefore, this procedure cannot be confirmed as 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (20525) provided on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a specialist on April 1, 2021.

You asked the Plan to waive the copayment for the telehealth visit with a specialist. You say that you did not see the doctor face-to-face, it was just a telephone call. You do not think you should be charged a copayment for this service. The Plan denied your request. The Plan says you were charged this 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 $40 copayment for telehealth visits and virtual check-ins with a specialist. 

You have been asked to pay a $40 copayment for the telehealth visit with a specialist. This copayment applies to visits that are conducted over the phone. 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 telehealth visit you had with a specialist on April 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) sessions.

You asked the Plan to pre-approve the additional PT sessions. You say that additional therapy is needed. The Plan denied your request. The Plan says continued PT is 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 pre-approve the additional PT sessions. 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 additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy, and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The patient has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient'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 the additional PT sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) sessions.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services provided on March 2, 2021.

You asked the Plan to waive the copayment for the ER services. You say that you do not want to pay this copayment because the enrollee was sent home with electrodes still on and the ER performed unauthorized tests. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for emergency room services. 

The enrollee has been asked to pay a $90 copayment for the ER services. This copayment applies regardless of your satisfaction with the ER services. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) services provided on March 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you are in need of a higher level of care. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 

We looked at this physician's review, 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient or outpatient dialysis services (90999) provided January 2, 2021 to January 30, 2021.

You asked the Plan to waive the copayment for the dialysis services. You say that you feel you shouldn't be liable for the charges because you were not told that the Plan replaces original Medicare. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.

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 Services to treat kidney disease. 

You have been asked to pay $1,687.40 ($129.80 x 13 visits) for the dialysis services. The dialysis services fall within the Services to treat kidney disease 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 inpatient or outpatient dialysis services (90999) provided January 2, 2021 to January 30, 2021.