Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee and billed under code 10061.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 10061 (1 unit) remains not supported. The documentation submitted did not include documentation of an Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple; therefore, the billed service cannot be verified. Of note, there is a more appropriate Current Procedural Terminology (CPT) code, 10060, for the service provided. It is noted that multiple attempts were made to contact the provider for additional information.The billed services were not supported. An appeal was submitted by the provider. The documentation submitted during the course of the original investigation was again thoroughly reviewed.An appeal was submitted by the provider with no new medical records. Documentation submitted on appeal consists of an Appeal Letter and duplicates of medical documents previously reviewed. Medicare coverage criteria are not 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 and when necessary support medical records to support the services billed. In this case, the records provided are insufficient to support the services billed for code 10061.Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee and billed under code 10061.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee has stage 2 sacral and stage 4 left buttock pressure sores that are assessed and dressing changed 2 times a week by home health. The enrollee's prior level of function was needing minimal assistance for activities of daily living and being independent for ambulation. The enrollee's current level of function is needing moderate assistance for bed mobility, transfers, ambulation and basic activities of daily living. The enrollee needs minimal assistance for dressing. The enrollee was approved for skilled nursing facility (SNF) care on 2/26/20 for weakness, shortness of breath, multiple falls, and pressure ulcers.The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee does not require this on an intensive rehabilitation facility therapy program level 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laparoscopic bilateral salpingectomy.You asked the Plan to pre-approve a laparoscopic bilateral salpingectomy. You say that the requested procedure is medically necessary.The Plan denied your request. The Plan says the information does not show that the enrollee has finished treatment for an infection, has a tumor, or has an ectopic pregnancy.The Plan follows Medicare rules. Medicare rules say that elective tubal ligation is nationally non-covered if the primary indication is sterilization.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a laparoscopic bilateral salpingectomy. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is a 40-year-old woman who wants permanent sterilization. She is currently using Nexplanon, a etonogestrel implant, which is due to come out this year. The enrollee reported pelvic pain. There were no abnormal findings on gynecological examination. An ultrasound demonstrated a right ovariancyst, but the enrollee's pain is worse on the left side. The enrollee would like to proceed with laparoscopic evaluation, along with bilateraal salpingectomy, Nexplanon removal, D&C, and a hysteroscopy to evaluate irregular bleeding, possible treatment ofendometriosis and/or ovarian cysts. It is noted that the enrollee is done childbearing, and wants permanent sterilization. There is no documentation of an illness, injury, or tumor in the fallopian tubes.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 laparoscopic bilateral salpingectomy have not been met.Therefore, we decided that the Plan does not have to pre-approvea laparoscopic bilateral salpingectomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe acute inpatient hospital care.You asked the Plan to pre-approveacute inpatient hospital care. You saythat you are requesting review of denial of services.The Plan denied your request. The Plan says you do not have complicationsrequiring inpatient level admission and the care you need can be given at a lower level of care such as outpatient or if necessary, as observation at the hospital.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 looked at 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. The doctor has not submitted any medical records to support that he has an expectation that you will likely require more than two midnights of hospital care. Without documentation to support the need for a two-midnight stay, we cannot determine whether these criteria are met.Therefore, we decided that the Plan does not have to pre-approvethe acute inpatient hospital care.
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
documentation does not reveal that the enrollee's current medical status requires the intensity of an IRF stay
with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of
physical therapy (PT) and occupational therapy (OT) but the enrollee does not require this on an intensive
rehabilitation facility therapy program level 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Euflexxa injections provided from October 8, 2019 through October 22, 2019.
You asked the Plan to waive the coinsurance for the injections. You say that you have never had a cost share for Euflexxa injections. The Plan denied your request. The Plan says that the claim processed 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Medicare Part B prescription drugs 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 Euflexxa injections provided from October 8, 2019 through October 22, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for nursing facility care (99309) provided on September 16, 2019.You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration based on the records submitted. The Plandenied your request. The Plan says that this claim was billed with an incorrect place of service.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The provider's services would not require authorization if they were provided during a Medicare Part A-covered SNF stay as stated in the appeal letter. The Plan declined to provide any information to confirm or deny whether or not this stay was being covered and only stated that the POS code reported by the provider was not for a Part A covered stay. We find that the plan did not forward sufficient information to determine whether the out of network provider's services could be covered without separate authorization. Therefore, we decided that the Plan has topay for nursing facility care (99309) provided on September 16, 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: Lab
Decision: Favorable

We decided that the Plan has to pay for the gastrointestinal pathogen services (CPT Code 0097U) you received on October 11, 2019.You asked the Plan to pay for the services provided. You say that it is imperative that you get to the bottom of your problem so that your life can go back to normal.The Plan denied your request. The Plan says that the plan does not cover services that are not medically necessary.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided thatthe services will not be covered. Priority Health follows these rules.The provider at issue is a contract provider. The file does not show that Priority Health provided notice that the services provided would not be covered. Under Medicare rules, this means the services provided is considered approved by Priority Health. Therefore, we decided that the Plan has to pay forthe gastrointestinal pathogen services (CPT Code 0097U) you received on October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forincontinence supplies.You asked the Plan to pay forincontinence supplies. You say that you received a denial notice for the purchased supplies. You say that your primary care doctor requested the supplies for you.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pay forincontinence supplies.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from February 8, 2019 to February 15, 2019.
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says that services from non-participating providers are not covered unless they are authorized by the Plan before the services are provided.
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 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 home health services provided from February 8, 2019 to February 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 29, 2019.You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration as these services were medically necessary. The Plan denied your request.The Plan says train of four is considered a bundled procedure and payment for it is included in payment for the already approved neuromonitoring.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95999 is not supported in the record. Specifically, payment for train of four monitoring is included in the payment for the approved, primary neuromonitoring service. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 29, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from September 23, 2019 to November 8, 2019.You asked the Plan to waive the copayments for the physical therapy visits. You say that you were told you did not have any copayments. You say you should not be responsible for the copayments. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for physical therapy at an in-network specialist's office. You have been asked to pay a $10 copayment for the physical therapyvisits. ($10 x 15 visits = $150). The physical therapy visits fall within the "Outpatient rehabilitation services" 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 acontractual 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 physical therapy visits provided from September 23, 2019 to November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the provision of test materials and equipment for home International Normalized Ration (INR) monitoring (G0249) provided on March 30, 2019, April 14, 2019, April 29, 2019, July 11, 2019, and July 22, 2019.You asked the Plan to pay for the provision of test materials. You say that this should be covered.The Plan denied your request. The Plan says the billing does not correspond to the covered frequency for testing.The Plan must follow Medicare rules. Medicare rules say that self-testing with the device should not occur more frequently than once a week. One unit of G0249 is four tests which have been completed and reported to the provider over a period of four weeks or greater.We looked at the file and Medicare rules. Each unit of G0249 represents four test, and testing should not occur more than once a week. These claims were billed with G0249 with dates of service less than four weeks apart, meaning the covered frequency has been exceeded. Based on this information, we decided that Medicare rules for coverage of the provision of test materials have not been met.Therefore, we decided that the Plan does not have to pay for the provision of test materials and equipment for home International Normalized Ration (INR) monitoring (G0249) provided on March 30, 2019, April 14, 2019, April 29, 2019, July 11, 2019, and July 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from March 11, 2019 to April 20, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate settingother than a SNF.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. 
The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decidedthat Medicare rules for coverage of the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from March 11, 2019 to April 20,2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. You say that you cannot get out of bed or chair without assistance.The Plan denied your request. The Plan says you have no skilled nursing or therapy needs.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our physician reviewer found that from a nursing perspective, you had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a modified independent to independent level with functional mobility. Yourequire varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 services have not been met. Therefore, wedecided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services.
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 services are medically necessary. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 14, 2020 with congestive heart failure. He is non-toxic and afebrile. He needs moderate assist with upper body dressing and maximal to total body assist with activities of daily living, transfers, and gait. He has no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear that he would be able to fully benefit from and participate in an intensive therapy program 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 for the enrollee.