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

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee's doctors believe that admission to an IRF is necessary.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the services needed could be received in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 enrollee does require physical therapy and occupational therapy services but, based on the medical records provided, does not require an intensive inpatient rehabilitation therapy program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 1, 2019 to November 30, 2019.
You asked the Plan to pay for the 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 SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from August 23, 2019 to February 10, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from November 1, 2019 to November 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99350) provided on April 1, 2019.
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the billed code does not appropriately reflect the services provided by the resident nurse.
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 99350 is home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family. 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 home visit. Our reviewer says that CPT code 99350 is not supported by the medical record. Our reviewer found the services was provided in the home by a registered nurse, not a physician, physician's assistant or nurse practitioner. 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 home visit have not been met. Therefore, we decided that the Plan does not have to pay for a home visit (99350) provided on April 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNeulasta.You asked the Plan to pre-approveNeulasta. You say that Neulasta is medically necessary.The Plan denied your request. The Plan says Neulasta is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Neulasta. Our reviewer says that Neulasta is not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of vulvar cancer. The enrollee is receiving a chemotherapy regimen which consists of Carboplatin, Paclitaxel, and Bevacizumab. IDSA guidelines recommend that the prophylactic use of colony stimulating factors such as Neulasta, be considered for afebrile patients in whom the anticipated risk of fever and neutropenia is greater than or equal to 20 percent. The enrollee's cancer treatment regimen is not associated with a risk of fever and neutropenia that is greater than or equal to 20 percent.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta have not been met.Therefore, we decided that the Plan does not have to pre-approveNeulasta.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveporcelain fused noble metal crowns for teeth #4 and 6 (D6752) and a bridge for tooth #5 (D6242).You asked the Plan to pre-approveporcelain fused noble metal crowns for teeth #4 and 6 and a bridge for tooth #5. You say that the services are necessary.The Plan denied your request. The Plan says the requested services are not a covered benefit.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 among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveporcelain fused noble metal crowns for teeth #4 and 6 (D6752) and a bridge for tooth #5 (D6242).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 18, 2019 by an out of network (OON) provider.You asked the Plan to pay forlaboratory testing. You say that you are appealing with supporting documentation.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.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 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 forthe medical services provided on July 18, 2019 by an out of network (OON) provider.
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 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 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 there are no services at the LTACH that the enrollee requires that are not already
available and covered at the current setting. They can effectively get the needed care staying where they are
and when stable for discharge, they could go to a lower level of care. Therefore, this request for LTACH
services will be considered not medically necessary at this time.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cystoscopy provided on January 16, 2020.
You asked the Plan to reduce the copayment for the cystoscopy. You say that you feel that the cost is too high for a 30-minute long procedure. You say you do not have the money to cover this copayment. 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 $400 copayment for an outpatient hospital facility. You have been asked to pay a $400 copayment for the cystoscopy. The cystoscopy 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 reduce the copayment for the cystoscopy provided on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Biocept Breast Cancer Profile circulating tumor cell (CTC) testing provided on August 7, 2019.
You asked the Plan to pay for CTC testing. You say that the enrollee's treating physician determined that this testing was medically necessary. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were not covered by Medicare for this date of service.
The Plan must follow Medicare rules. Medicare rules say that circulating tumor cell tests were excluded from Medicare coverage for date of service August 7, 2019. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CTC testing have not been met. Therefore, we decided that the Plan does not have to pay for circulating tumor cell (CTC) testing provided on August 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip x-ray rendered on February 19, 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 73502-26 is not supported.
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of
the PC of radiology services when furnished in a different payment locality than the TC.
We looked at the file and Medicare rules. We looked at the file and Medicare rules. The file shows that the PC
and TC were not performed in different payment localities. 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 hip x-ray rendered on February 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthediagnostic colonoscopy provided on January 29, 2019.You asked the Plan to waive the copayment forthe diagnostic colonoscopy. You say that you never went to this facility in January. You say you had polyps removed from procedures in May and June/July. 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 $150 copayment for each Medicare-covered in-network ambulatory surgical center visit. You have been asked to pay a $150 copayment for the diagnostic colonoscopy. The diagnostic colonoscopyfalls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers"benefit category. The medical record shows you had polyps removed during the colonoscopy on January 29, 2019.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 forthediagnostic colonoscopy provided on January 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing services provided on July 10, 2019.
You asked the Plan to pay for the testing services. You say that the codes are supported by the physicians custom profile. The Plan denied your request. The Plan says the billed codes 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. We find that the CPT codes are not supported in the medical record. There is no evidence that shows the test was individualized to identify specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing services provided on July 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on February
21, 2020.
You asked the Plan to waive the copayment for the ambulance ride. You say that you cannot afford this
copayment. 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 $150
copayment per trip, each way.
You have been asked to pay a $150 copayment for the ambulance ride. The ambulance ride falls within the
"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 copayment for the
ambulance ride provided on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe pulmonary rehabilitation services provided from February 4, 2020 to February 7, 2020.You asked the Plan to waive the copayments forthe pulmonary rehabilitation services. You say that you have 30 visits per year and that the deductible does not apply. You say you should not be responsible for the $75 charge. 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 $25 copayment for each in-network Medicare-covered pulmonary rehabilitation service. You havebeen asked to pay a $25 copayment for the pulmonary rehabilitation services on each date of service. ($25 x 3 = $75). The pulmonary rehabilitation services 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 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 forthe pulmonary rehabilitation services provided from February 4, 2020 to February 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission 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 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 enrollee's anemia has resolved after transfusion and supratherapuetic INR is back in range. The documentation does not support that the enrollee requires an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. While the enrollee requires additional physical therapy and occupational therapy, the enrollee's care needs can be met at a lower level of 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 doesnot have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided on February 20, 2020.You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.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 99233 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99233 is not supported in the medical record. Specifically, this code was billed with diagnosis code F05 (delirium due to known physiological condition). This code is a code first the underlying physiological condition. When there  is  a  "code  first"  note  and  an  underlying  conditionis present, the underlying condition should be sequenced first, if known. Therefore, this diagnosis code should not be reported first. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have notbeen met.Therefore, we decided that the Plan does not have to pay forthe subsequent hospital care services coded 99233 provided on February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea low air loss pressure reducing mattress.You asked the Plan to pre-approvea low air loss pressure reducing mattress. You say that the requested low air loss pressure reducing mattress is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested low air loss pressure reducing mattress.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 low air loss pressure reducing mattress. Our reviewer says that the enrollee does not meet criteria for the requested low air loss pressure reducing mattress. Our physician reviewer found the enrollee does not have a covered indication for a group 2 support surface. The enrollee has no current physical exam evidence of multiple stage II pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, during which time the enrollee has been on a comprehensive ulcer treatment program. The enrollee has no physical exam evidence currently of large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis or no physical exam evidence of a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days.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 low air loss pressure reducing mattress have not been met.Therefore, we decided that the Plan does not have to pre-approvea low air loss pressure reducing mattress