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

We decided that the Plan does not have to reduce the coinsurance for the cholecystectomy provided on October 24, 2019.
You asked the Plan to reduce the coinsurance for the cholecystectomy. You say that you would like this to be processed as in-network. 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 40% coinsurance for out-of-network same day outpatient surgery. You have been asked to pay $1,696.88 which is 40% of the allowed amount for the cholecystectomy. The allowed amount is $4,242.20. ($4,242.20 x 40% = $1,696.88). The cholecystectomy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that the provider is out-of-network.
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 coinsurance for the cholecystectomy provided on October 24, 2019.
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 presented to the emergency department on 1/26/20 for left hip fracture. She is now status post open reduction internal fixation (ORIF). The enrollee's prior level of function was independent and lives alone in a one story with 8 steps to enter. The enrollee has family support. On 1/28/20 physical therapy (PT) notes reveal the enrollee needs moderate assistance with ambulation 8-12 feet. The enrollee is weight-bearing as tolerated with hip precautions. Occupational therapy (OT) notes state the enrollee needs moderate assistance for bathing, toileting, and upper body dressing. Lower body is at maximum assist. OT notes supervision to minimal assist for bathing, dressing upper extremity is minimal assist, and lower extremity dressing is moderate assist. Grooming is supervision. The enrollee can transfer from supine to sit with minimal assist. The enrollee can move off the bed with minimal assist. The enrollee can sit to stand with moderate assist. The enrollee needs minimal assistance to push up with right upper extremity into bed to sit erect. 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 PT and 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician serves provided to the enrollee on June 21, 2019 and billed under code 99292.
You asked the Plan to pay for physician services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing 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. 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 service. Our reviewer says that Medicare coding criteria are not met. Our physician reviewer found based on the documentation provided, the use of the 59 modifier is not appropriate, as the care provided was all part of the same event. The time for the initial consult and subsequent family interaction should be combined and that number used to determine how many units of CPT 99292 should be billed in addition to CPT 99291. It is not necessary to bill the additional units of CPT 99292 with the 59 modifiers. 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 physician serves provided to the enrollee on June 21, 2019 and billed under code 99292.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a coronary artery bypass (33518) provided on July 9, 2019.You asked the Plan to pay for the coronary artery bypass. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the operative report did not include documentation of coronary artery bypass, using venous graft(s) and arterial graft(s), for 2 venous grafts.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 33518 is coronary artery bypass, using venous graft(s) and arterial graft(s); 2 venous grafts (List separately in addition to code for primary procedure).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 coronary artery bypass. Our reviewer says that the billing of 33518 is not supported. The documentation shows that the enrollee underwent a two-vessel coronary artery bypass graft. One of the bypasses was performed with a vein, the other with an artery. Our reviewer found the billing should use a code indicating the use of both veins and arteries, but that only one vein graft was used. An add-on code should be used to show the use of the arterial graft.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the coronary artery bypass have not been met. Therefore, we decided that the Plan does not have to pay for a coronary artery bypass (33518) provided on July 9, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Opdivo injection (J9299).
You asked the Plan to pre-approve Opdivo injection. You say that the service is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Opdivo injection. Our reviewer says that the service is medically necessary. Our physician reviewer found according to the provided records, the physician's statement states that due to hepatitis and liver damage associated with both lenvatinib and sorafenib, typically first line options for this condition, Opdivo, approved for the treatment of hepatocellular carcinoma, was considered and requested to reduce any potential harm to the enrollee, which is reasonable. Therefore, this request for Opdivo will be considered medically necessary and appropriate as well as safe and effective for this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo injection have been met. Therefore, we decided that the Plan has to pre-approve Opdivo injection (J9299).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intracept Procedure to treat chronic vertebrogenic pain.
You asked the Plan to pre-approve Intracept Procedure to treat chronic vertebrogenic pain. You say that the requested Intracept procedure is medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is not medically necessary.
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 Intracept Procedure to treat chronic vertebrogenic pain. Our reviewer says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the enrollee is diagnosed with spondylosis without myelopathy or radiculopathy, lumbosacral region. The Intracept procedure is experimental at this time. More research is needed to show safety and efficacy. The requested Intracept procedure is not medically reasonable or 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 Intracept Procedure to treat chronic vertebrogenic pain have not been met. Therefore, we decided that the Plan does not have to pre-approve Intracept Procedure to treat chronic vertebrogenic pain.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (S9131, S9129 and S9123) provided on November 15, 2018 through November 28, 2018.
You asked the Plan to pay for the home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a valid HIPPS code is required for processing.
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 codes S9131, S9129 and S9123 are not supported in the record. Specifically, the fifth position of the HIPPS code on the submitted claim is, "S." There were no supplies billed on this claim. The fifth position of the HIPPS code should be recorded as numbers 1 through 6 if the Home Health Agency is aware that supplies were not provided during an episode. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (S9131, S9129 and S9123) provided on November 15, 2018 through November 28, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.ThePlan 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 fileand 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute inpatient hospital care on 1/19/20 with shortness of breath. Enrollee intubated and went into cardiac arrest, severe cardiomyopathy with EF of 25%, and end-stage renal disease (ESRD) on hemodialysis. The enrollee is lethargic and unable to participate in advance care planning and is with intermittent confusion.There is no documentation provided necessitating admission to a LTACH. The member still requires acute level of care hospital services and is receiving appropriate care at the present acute care facility. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH thatthe enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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-approvelong term acute carehospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hip Kit (E1399).
You asked the Plan to pre-approve a Hip Kit. You say that you are requesting a hip kit for the member. The member has been diagnosed with unilateral primary osteoarthritis of the right hip. The hip kit consists of sock aid, dressing stick, a reacher, shoehorn, long-handled bath sponge, and elastic shoelaces. The Plan denied your request. The Plan says that the Hip Kit is excluded from Medicare coverage.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a Hip Kit (E1399).
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 was hospitalized from 12/30/19-1/7/20 for pneumonia and congestive heart failure exacerbation. On 1/7/20 the enrollee transferred to SNF for skilled therapies. The enrollee and her physician feel the enrollee requires acute inpatient rehabilitation and that this cannot be accomplished at a lower level of care. Prior to Dec. 2019 the enrollee was moderate independent with rolling walker with ambulation. At the start of SNF care the enrollee was not ambulating but progressed to ambulation of 115 feet with a rolling walker with contact guard assist by 1/28/20. She required frequent rest breaks throughout. She is stand-by assist for toileting and set up for donning shoes/robe. 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 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 is
progressing in SNF therapy and does not require therapy 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says there are no skilled nursing needs or skilled therapy needs that require this level of care.
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 the enrollee is currently undergoing treatment at an ACH for pneumonia and pressure sores. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital for hepatic encephalopathy. The enrollee is not intubated/ventilated. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. Medicare coverage criteria are not 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to issue reimbursement for the eyeglasses (V2781, V2702) purchased  on May 6, 2019.
You asked the Plan to issue reimbursement for the eyeglasses. You say that you are requesting reconsideration
of the Plan's denial. The Plan denied your request. The Plan says that you have exceeded the allowable vision
benefit for the calendar year.
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. Specifically, the Explanation of Benefits Statement dated November 11, 2019
provided by the plan, indicates that you purchased another pair of eyeglasses; however, the date of service was
not indicated on this statement. The plan has not demonstrated that you have exceeded your allowable vision
benefit for the 2019 calendar year. Therefore, we decided that the Plan has to issue reimbursement in the
amount of $100 for the eyeglasses (V2781, V2702
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Dexcom G4 Platinum Transmitter Kit.
You asked the Plan to pre-approve a Dexcom G4 Platinum Transmitter Kit. You say that the requested Dexcom G4 Platinum Transmitter Kit is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet Medicare criteria.
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. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. Therefore, we decided that the Plan has to pre-approve a Dexcom G4 Platinum Transmitter Kit.