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

We decided that the Plan has to pay for the inpatient hospital readmission provided from March 2, 2021, to March 4, 2021.
You asked the Plan to pay for the inpatient hospital care. You say that you followed all the proper procedures and the Plan should pay for the services provided. The Plan denied your request. The Plan says that the enrollee was readmitted to the same facility for treatment of the same conditions within thirty days of the previous admission. Therefore, this admission will not be separately reimbursed.
The Plan follows Medicare rules. Medicare rules say that a readmission to an acute, general, short-term hospital occurring less than 31 calendar days from the date of discharge from the same or similar facility, is covered when the services are medically necessary and did not occur as the result of a premature discharge from the same hospital and was not the result of an attempt by the same hospital to circumvent the PPS. 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 inpatient hospital care. Our reviewer says that they have determined that the readmission was medically necessary and was not the result of a premature discharge from the same hospital. Our physician reviewer found that the enrollee was first admitted to the hospital from February 4, 2021, to February 8, 2021, for treatment of pneumonia with hypoxia, infectious gastroenteritis, and gastritis. The enrollee improved symptomatically and recovered well. On the date of discharge, the enrollee's vital signs were unremarkable, and they were in no distress. Their physical exam was normal, and the enrollee was instructed to complete a course of oral antibiotics.
The enrollee was brought to the emergency department by ambulance on March 2, 2021, with a 2-3-day history of nausea, fatigue and hyperglycemia. Discharge diagnoses include vomiting, diarrhea, couch, acute respiratory failure with hypoxia, and dizziness. It is the opinion of our physician reviewer that the readmission to the hospital on March 2, 2021, was medically necessary in this case and did not result from a previous premature discharge from the same hospital. 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 inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the inpatient hospital readmission provided from March 2, 2021, to March 4, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that this will limit chances of falling in the shower. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95822, 95927, 95938) provided March 12, 2020.
You asked the Plan to pay for the neuromonitoring services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are not eligible for separate payment.
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 95822, 95927, & 95938 is not supported in the medical record. Specifically, the services were provided when the enrollee was an inpatient. Payment is included in the inpatient hospital services. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95822, 95927, 95938) provided March 12, 2020.
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. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 5, 2020.

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 procedure code 29999 is not supported.

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 29999 is unlisted procedure, arthroscopy. 

We find that CPT code 29999 is not supported in the medical record. Specifically, there is no documentation of an independent unlisted arthroscopy procedure. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on November 5, 2020.
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. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a hip fracture and non-surgical management of a subdural hematoma after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81291, 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81439, 81479) provided November 25, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular-respiratory disease. 

We looked at the file and Medicare rules. Cardiovascular risk assessment panels are not a covered service. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81291, 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81439, 81479) provided November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Oncology (thyroid) gene expression
analysis (81546) provided on March 9, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to
the service provided.

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 molecular and predisposed genetic testing.

You have been asked to pay $640 (Plan allowed amount of $3,200 x 20% coinsurance) for the genetic testing
provided. 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 Oncology (thyroid) gene expression
analysis (81546) provided on March 9, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on March 23, 2021.
You asked the Plan to pay for genetic testing. You say that prior authorization is not required for this test, and the Plan is obligated to cover it according to Medicare regulations. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because prior authorization not obtained for this testing.
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. 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 that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on March 23, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flexible protective outer surface covering system (L5962).

You asked the Plan to pre-approve a flexible protective outer surface covering system (L5962). You say that the requested flexible protective outer surface covering system (L5962) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested flexible protective outer surface covering system (L5962).

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 a flexible protective outer surface covering system (L5962). Our reviewer says that the enrollee does not meet criteria for the requested flexible protective outer surface covering system (L5962). Our physician reviewer found the documentation does not support that this enrollee has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704. The criteria for the flexible protective outer surface covering system (L5962) have not been met. 

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 flexible protective outer surface covering system (L5962) have not been met. Therefore, we decided that the Plan does not have to pre-approve a flexible protective outer surface covering system (L5962).
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. You say that you cannot do many daily tasks and you do not have
anyone to assist you at home. The Plan denied your request. The Plan says the stay is 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 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 the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
confusion and a urinary tract infection. Medical conditions are stable. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. You do 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 you 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a virtual office visit provided by a participating provider on February 18, 2021.

You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness exam. The Plan denied your request. The Plan says the correct copayment has been 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 $10 copayment for physician/practitioner services/PCP office visit.

You have been asked to pay a $10 copayment for an office visit. If you receive services that address a medical condition during an annual wellness exam, additional cost-share may apply; therefore, the correct copayment has been applied. An office visit falls within the physician/practitioner services/PCP office visit 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 virtual office visit provided by a participating provider on February 18, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

You asked the Plan to pay for refraction. You say that you do not find any exclusion for refractions in your benefits, and this claim should be processed. The Plan says that the denial of payment for this service is correct, because this charge is not separately reimbursed from the eye exam itself.
We decided that the Plan has to partially pay for refraction.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 1 routine eye exam per year, including refraction and dilation, up to a $75 allowance when using an out-of-network provider.
We looked at the file and the Plan's rules. You received a routine eye exam with refraction, both of which are covered by the Plan's supplemental vision benefits and included in the allowance for out-of-network providers. The total charge for these services was $85, however the Plan only reimbursed you in the amount of $35. The Plan claims that the charge for eye refraction is not separately reimbursable. The Plan contract does not clearly state that eye refractions are excluded from coverage or are not separately reimbursable under the Plan's supplemental vision benefits. The Plan contract does state that refractions are included in the $75 allowance for routine eye exams. Therefore, we decided that the Plan must pay an additional $40 for refraction.
We also decided that the Plan does not have to fully pay for refraction.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefits that exceeds Medicare coverage rules. For that reason, the Plan's coverage rules apply in this case. The Plan covers 1 routine eye exam per year, including refraction and dilation, up to a $75 allowance when using an out-of-network provider. The enrollee is responsible for any amount over $75 when using an out-of-network provider.
The total charge for this claim is $85. The Plan paid $35 during the original processing of the claim, and the Plan is required to pay an additional $40 according to your benefits. This results in the full $75 allowance being exhausted, so you are responsible for the remaining $10 which is over the $75 allowance amount. Therefore, we decided that the Plan does not have to fully pay for refraction.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a polycarbonate lens (V2784) provided on March 4, 2021.

You asked the Plan to pay for a polycarbonate lens. You say that you have never used your benefit for glasses. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says you have a $200 allowance per year to use towards eyewear.

We looked at the file and the Plan's rules. The records show you exhausted your $200 maximum allowed benefit on March 4, 2021. The records also show that you purchased frames at an allowed amount of $68.40, progressive lenses at an allowed amount of $103, and an anti-reflective coating at an allowed amount of $28.60. You received the total allowed amount of $200 ($68.40 + $103 + $28.60 = $200). Based on this information, we decided that the Plan's rules for coverage of polycarbonate lens have not been met. Therefore, we decided that the Plan does not have to pay for a polycarbonate lens (V2784) provided on March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L1833, L2397) provided April 6, 2021 to April
7, 2021.

You asked the Plan to pay for the orthosis. You say that the items were medically necessary. The Plan denied
your request. The Plan says the documentation does not support the services billed.

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 proof of delivery. The record shows that the Plan made several attempts to
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay
for an orthosis (L1833, L2397) provided April 6, 2021 to April 7, 2021.