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

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you require acute rehab and that inpatient rehab for your condition has been recommended by your doctor. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you and/or your provider are requesting do not meet the requirements for approval.
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 that 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 peripheral vascular disease and had an above the knee amputation. Your 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9502 provided from August 12, 2019 to August 20, 2019.

You asked the Plan to pay for the home infusion therapy 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 S9502 is home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.

We find that CPT code S9502 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9502 provided from August 12, 2019 to August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on January 25, 2021.
You asked the Plan to pay for the office visit. You say that you were not informed the doctor is out of plan or that authorization was necessary. The Plan denied your request. The Plan says prior authorization was required but 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 the office visit provided by an out-of-network
provider on January 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a SNF stay provided from October 29, 2020, to November 24, 2020.

You asked the Plan to waive the co-payment for a SNF stay. You say that you do not understand the charges on the claim. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 co-payment for days 1-20, and a $178 co-payment for days 21-100 for SNF care.

You had a SNF stay from October 29, 2020, to November 24, 2020. You are not being charged a co-payment
for days 1-20 (October 29, 2020, to November 17, 2020). You are responsible to pay a $178 co-payment for days 21-26 (November 18, 2020, to November 23, 2020). The total amount you owe is: $178 (co-payment) x 6 (SNF days) = $1,068.

You have been asked to pay the total co-payment amount of $1,068 for a SNF stay. A SNF stay falls within the SNF care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for a SNF stay provided from October 29, 2020, to November 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because the member needs more skilled care before being discharged home. The Plan denied your request. The Plan says the member's care needs may be met in the current setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found continued care in the inpatient rehabilitation facility is appropriate until the patient is stable to transfer to 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost for cataract surgery provided on October 21, 2020 and November 4, 2020.
You asked the Plan to reduce the cost for cataract surgery. You say that you thought you were supposed to pay $300 and the rest of the $1,000 deductible. You say that you paid your $350 copayment for each surgery, but the doctor is charging $758.50. The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Your contract with the Plan also says that after you pay your $1,000 deductible, you pay a $350 copayment for each Medicare-covered outpatient surgery at an in-network ambulatory surgical center. The item or service you asked the Plan to waive the copayment for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time cataract surgery was received on October 21, 2020 and November 4, 2020. Therefore, $1,000 has been applied to meet your deductible.
Since your $1,000 has been met you have also been asked to pay a $350 copayment for each cataract surgery. 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 cost for cataract surgery provided on October 21, 2020 and November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on August 4, 2020.
You asked the Plan to pay for the extraction. You say that you have been having billing issues with your
insurance company. You say that you received a letter stating that you owe $91 and now you have a bill for
$550. You say that you only had your teeth cleaned in January 2021. You say that you feel that you do not owe
this amount. The Plan denied your request. The Plan says surgical extraction is not listed as a covered service.
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
surgical extraction (D7210) provided on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Genomind genetic panel (81225, 81230, 81231, 81380) provided on December 23, 2020.
You asked the Plan to pay for a Genomind genetic panel. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. We find that CPT codes 81225, 81230, 81231, and 81380 are not supported in the medical record. Specifically, the genetic testing performed was a panel and should be reported with one code. Based on this information, we decided that Medicare rules for coverage of a Genomind genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a Genomind genetic panel (81225, 81230, 81231, 81380) provided on December 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit coded 99327 provided on October 16, 2020.
You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 99327 is domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate 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 high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. We find that CPT code 99327 is not supported in the medical record. Specifically, this service was billed with place of service 12 (home). This service is not typically provided by a physician in the place of service 12 and must be provided in a facility setting. Based on this information, we decided that Medicare rules for coverage of the rest home visit have not been met. Therefore, we decided that the Plan does not have to pay for the rest home visit coded 99327 provided on October 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you believe that SNF care is medically necessary. The Plan denied your request. The Plan says you do not require daily skilled care in the SNF setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female with dementia with behavioral disturbance. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. Her lungs were clear. Regarding rehabilitation services, the beneficiary received physical therapy in the acute hospital. The beneficiary was at a minimal assist level with functional mobility including gait to 75 feet. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; However, there is no need for skilled therapy on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on February 3, 2021.

You asked the Plan to pay for the crown. You say that you believe this service is covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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 crown provided on February 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (HCPCS S9500) provided to the enrollee from October 15, 2020 to October 23, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an invalid procedure code for this 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 HCPCS code S9500 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services (HCPCS S9500) provided to the enrollee from October 15, 2020 to October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you had on January 21, 2021.
You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a
Medicare-covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear.
The services you asked the Plan to pay for are considered routine vision services or eyewear. Neither Medicare
nor your Part B plan covers eye refractions. Therefore, we decided that the Plan does not have to pay for the
eye refraction you had on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on March 3, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on July 6, 2020 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Check test strips.
You asked the Plan to pre-approve Accu-Check test strips. 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 follows Medicare rules. Medicare rules say that the rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-preferred brands). 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 Accu-Check test strips. Our reviewer says that the items are not medically necessary. Our physician reviewer found the medical records provided do not indicate why the plan's glucose monitors and strips would be inappropriate for you. The medical necessity and reasonableness, as defined by Medicare rules, of the requested service is not established. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Accu-Check test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Accu-Check test strips.
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 can be treated at a lower level of care.
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 patient does not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the patient does require physical and occupational therapy, there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different 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 does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a ventilator. You say that the enrollee will benefit from a ventilator to treat
carbon dioxide retention. The Plan denied your request. The Plan says the functionality exceeds the enrollee's
needs.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.

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 ventilator. Our physician reviewer
found that the enrollee has hypercapnic and hypoxic chronic respiratory failure, likely due to a combination of
obesity hypoventilation syndrome and COPD. She has been started on continuous positive airway pressure
(CPAP) device for obstructive sleep apnea that was confirmed on a home sleep study, but the CPAP is
reportedly ineffective. No PAP download data are provided. The enrollee may benefit from BiPAP, with an
attended PAP titration study to determine optimal settings.

Certain BiPAP devices can provide the AVAPS mode of support that has been ordered. Medicare does not
cover a home ventilator when used as BiPAP. There is no evidence of BiPAP failure. Therefore, the requested
ventilator is not medically 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 a ventilator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a home ventilator.