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

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. 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 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 health plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for osteomyelitis of the foot and end-stage renal disease. The enrollee is receiving wound care, a prolonged course of antibiotics and hemodialysis. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. 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 LTC 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, thorax; without contrast material (CPT Code 71270).

You asked the Plan to pre-approve the CT scan. You say that the enrollee is still experiencing shortness of breath and discomfort. The Plan denied your request. The Plan says the Medicare criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 the CT scan. Our physician reviewer found the enrollee has only had a chest x-ray suggestive of emphysema. There is a low risk of malignancy, no spirometry has been performed and the enrollee is being referred to a pulmonologist for further evaluation. Therefore, at this time the documentation does not support the performance of a CT scan as medically reasonable or necessary. 

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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT, thorax; without contrast material (CPT Code 71270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator (E1390).

You asked the Plan to pay for the oxygen concentrator. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says they do not pay for oxygen equipment that
is purchased.

The Plan must follow Medicare rules. Medicare rules say that the Plan may not pay for oxygen purchased on or
after June 1, 1989.

We looked at the file and Medicare rules. The file indicates that you purchased the oxygen concentrator. Based
on this information, we decided that Medicare rules for coverage of the oxygen concentrator have not been met.
Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390).
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee does not need the intensive care provided in an IRF.

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 is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. The enrollee does not require the intensity of services provided at 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain (D9110).

You asked the Plan to pay for the emergency treatment. You say that this was not an emergency treatment. You
also say you were in no pain. The Plan denied your request. The Plan says this service is not a covered benefit
under your dental plan.

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 pay for the
palliative (emergency) treatment of dental pain (D9110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrocentesis services coded 20611.

You asked the Plan to pay for the arthrocentesis services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.

We find that CPT code 20611 is not supported in the medical record. Specifically, the documentation submitted does not contain permanently recorded images to support the billed charge. Based on this information, we decided that Medicare rules for coverage of the arthrocentesis services have not been met. Therefore, we decided that the Plan does not have to pay for the arthrocentesis services coded 20611.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services.

You asked the Plan to pay for critical care (99291). You say that the Plan should pay this claim. The Plan
denied your request. The Plan says there is no documentation of critical care time spent.

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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted
does not support 30-74 minutes of critical care was performed, therefore the billed code cannot be verified.
Based on this information, we decided that Medicare rules for coverage of critical care (99291) have not been
met. Therefore, we decided that the Plan does not have to pay for critical care services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.

You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.

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 inpatient mental health treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, the enrollee does not meet the criteria for continued acute inpatient mental health treatment forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats to the safety of herself or others.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care.

You asked the Plan to pay for inpatient hospital care. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation you will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We 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 inpatient hospital care. Our reviewer says that the documentation does not support that criteria for inpatient hospital care are met in this case. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206).

You asked the Plan to pay for the topical application of fluoride varnish. You say that you cannot afford to pay for this service. The Plan denied your request. The Plan says this service is not covered.

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 pay for the topical application of fluoride varnish (D1206).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on May 13, 2020.

You asked the Plan to pay for the paramedic intercept services. The Plan denied your request. The Plan says
this item is not a covered benefit.

The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances.
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as
defined above.

The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the
paramedic intercept services provided on May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intravitreal injection of a pharmacologic agent, separate
procedure (67028) Injection, aflibercept, 1 mg (J078).

You asked the Plan to pay for the injection services. You say that the error has been resolved with a scratch out,
correct date labeled and a signature. Remit payment immediately for services rendered. The Plan denied your
request. The Plan says the records do not support the billed service.

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 is not supported in the medical record. Specifically, the documentation submitted do
not include documentation of intravitreal injection of a pharmacologic agent performed or documentation of
injection, aflibercept was administered on the date of service billed. The documentation indicates the services
was performed. Based on this information, we decided that Medicare rules for coverage of the
injection services have not been met. Therefore, we decided that the Plan does not have to pay for intravitreal
injection of a pharmacologic agent, separate procedure (67028) Injection, aflibercept, 1 mg (J078).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided y an out of network (OON) provider.

You asked the Plan to pay for the scooter. You say that you would like reconsideration because you paid out-of-pocket and were not aware that your insurance would cover the cost of the scooter. The Plan denied your request. The Plan says there is no prior authorization on file for the scooter.

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 for the medical services provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the pelvic x-ray.

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 72170 was not billed correctly.

The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures
performed on different anatomical sites.

We looked at the file and Medicare rules. Procedure code 72170 was billed with modifier RT, which is
improper because this is a bilateral code. Therefore, we decided that the Plan does not have to pay for the
pelvic x-ray.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided by an out-ofnetwork (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior
authorization was not obtained.

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 had network providers
available who could have provided the items/services at issue in this appeal. 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 for lab work provided by an
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because this service was approved by the referring physician. The Plan denied your request. The Plan says this service has not been billed correctly.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the record does not include a physician order or clear intent to order specific lab services in the medical record. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that the enrollee is not ready to be sent home. The
Plan denied your request. The Plan says that there is not a daily skilled medical or therapy need.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician services provided by an out-of-network provider.

You asked the Plan to pay for physician services. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says that prior authorization was not obtained.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to provide a 2018 EOC. Therefore, we decided that the Plan has to pay for physician services provided by an out-of-network provider.

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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services.

You asked the Plan to pay for the emergency room services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Explanation of Benefits from the enrollee's primary insurance carrier is needed before this claim can be considered.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer for payment. As the secondary insurer, the Plan cannot be held responsible for the emergency room services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the emergency room services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care.

You asked the Plan to pay for the subsequent nursing facility care. You say that the services provided were
medically necessary. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the subsequent nursing facility care.