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 (99291) provided on September 16, 
2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the primary diagnosis reported is 
considered a secondary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99291 is not supported in the record. Specifically, this claim was billed with R65.21 as 
the primary diagnosis. Per the ICD-10, diagnosis code R65.21 has a code first note, indicating that the 
underlying condition should be sequenced first. Based on this information, we decided that Medicare rules for 
coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to 
pay for the critical care services (99291) provided on September 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of a LTACH 
admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that it appears that you are improving and should only require short term additional 
acute care services which can safely be received at the current facility until completed. You do not require 
services at the LTACH that are not already available at the current facility. There are no services at the LTACH 
that you require that are not already available and covered at the current facility. Therefore, this request for 
LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may 
be considered soon when treatment has been completed. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast biopsy provided on August 13, 
2020. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you should not have a 
copayment for this service. The Plan denied your request. The Plan says the copayment amount you are being 
charged is correct. 
 
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 $365 
copayment for outpatient surgery at an outpatient hospital facility.  
 
You have been asked to pay $365 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 a breast biopsy provided on 
August 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for a left knee replacement. Her 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. The medical record documents a need for physical 
and occupational therapy but not for an intensive rehabilitation program. Medically necessary services could be 
provided at a low level of care. 
 
Additionally, there is a not 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an L3916 wrist/hand orthosis provided to the enrollee.

You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says medical necessity has not been established.

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 pay for this claim. Our reviewer says that medical necessity has not been established. Our physician reviewer found the L3916 orthosis is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as the requested L3916 is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The documentation does not reveal subjective and objective exam findings of the wrist/hand that indicate a need for this brace. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for an L3916 wrist/hand orthosis provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit.

You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.

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 $45 copayment for urgent care services in a specialist's office.

Review of the file shows that you received urgent care services. You have been asked to pay a $45 copayment for the services. The services fall within the urgent 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 office visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an inpatient hospital stay and an observation stay.

You asked the Plan to waive the copayments for an inpatient hospital stay and an observation stay. You say that you disagree with the charges because you were part of a study and should not be responsible for the charges. 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 a $295 copayment for inpatient hospital stays and a $200 copayment for observation services.

You had an inpatient hospital stay. Therefore, you are responsible to pay the $295 copayment.

You had an observation stay. Therefore, you are responsible to pay the $200 copayment.

The total copayment amount you owe is: $495.

You have been asked to pay the total copayment amount of $495 for an inpatient hospital stay and an observation stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. An observation stay falls within the outpatient hospital 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 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 an inpatient hospital stay and an observation stay.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital bed provided on September 19, 2020. 
 
You asked the Plan to pay for the hospital bed. You say that the claim should be covered because the enrollee 
was released from hospice prior to this date of service. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
enrollees terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 12, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital bed 
provided on September 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient mental health stay provided 
from October 6, 2020, to October 15, 2020. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that you had no choice in going to this 
facility. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $390 
copayment per day for days 1 to 4 and $0 copayment for additional days for inpatient mental health stay. This 
inpatient stay lasted 9 days, resulting in a copayment obligation of $1,560. 
 
You have been asked to pay $390 copayment per day for days 1 to 4 and $0 copayment for additional days for 
inpatient stay. Inpatient stay falls within the Inpatient 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 copayment for an inpatient mental health stay provided from October 6, 2020, to 
October 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for sepsis, urinary tract infection and encephalopathy. His 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. The medical record documents a need for physical 
and occupational therapy but not for an intensive rehabilitation program. Medically necessary services could be 
provided at a low level of care. 
 
Additionally, there is a not reasonable expectation that this patient will be able to fully participate in and 
benefit from an 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient surgical services rendered 
on August 31, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the coinsurance was applied 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 30% 
coinsurance for out-of-network surgery services at an outpatient hospital.  
 
Review of the file shows that you received outpatient surgical services at an out-of-network outpatient hospital 
on August 31, 2020. You have been asked to pay a 30% coinsurance for these services. These services fall 
within the out-of-network surgery services at an outpatient hospital 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 outpatient surgical services rendered on August 31, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care provided on September 27, 2020. 
 
You asked the Plan to pay for the critical care. The Plan denied your request. The Plan says Original Medicare 
would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's 
terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 1, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the critical care 
provided on September 27, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the needle electromyography. We decided that the Plan does not have 
to pay for train of four monitoring.  
 
You asked the Plan to pay for the needle electromyography and train of four monitoring. You say that you 
would like reconsideration because you billed these services with the correct place of service code. The Plan 
says that the billed services are not supported. 
 
We decided that the Plan has to pay for the needle electromyography.  
 
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent 
efforts to gather and forward information to the Independent Review Entity (IRE). 
The Plan has failed to forward sufficient information to substantiate their denial. There is no evidence provided 
in the case file to indicate that the member was registered inpatient on the billed date of service. It is the burden 
of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated, and we 
must find in your favor. Therefore, we decided that the Plan has to pay for the needle electromyography.  
 
We also decided that the Plan does not have to pay for train of four monitoring. 
 
The Plan follows Medicare rules. Medicare rules say that all services integral to accomplishing a procedure are 
considered bundled into that procedure and, therefore, are considered a component part of the comprehensive 
code. 
 
Train of four testing does not fit the criteria for Current Procedural Terminology (CPT) 95937. It is 
inappropriate to bill the code for neuromuscular junction testing when train of four monitoring is performed. 
Additionally, train of four monitoring is considered integral to the primary procedure and is not separately 
reimbursable. Therefore, we decided that the Plan does not have to pay for train of four monitoring. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing test (92557).

You asked the Plan to waive the copayment for the hearing test. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct amount was applied.

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 $100 copayment for outpatient hospital services.

You have been asked to pay a $100 copayment for the hearing test. The hearing test falls within the outpatient hospital 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 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 a hearing test (92557).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings, periodic oral evaluation, and prophylaxis.

You asked the Plan to pay for the bitewings, periodic oral evaluation, and prophylaxis. You say that Medicare does not cover preventive dental services, and you do not understand why these services were denied. The Plan denied your request. The Plan says these services were rendered by a Medicare opt out provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the bitewings, periodic oral evaluation, and prophylaxis.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the ambulance transport provided on March 5, 
2020. 
 
You asked the Plan to waive the copay for the ambulance transport. You say that this should not be your 
responsibility. The Plan denied your request. The Plan says that your benefits were applied 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 $230 
copay per one way trip for Medicare-covered ground ambulance services.  
 
You have been asked to pay a $230 copay for the ambulance transport. The ambulance transport falls within 
the one-way trip for Medicare-covered ground ambulance 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 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 copay for the ambulance transport provided on March 5, 2020.