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

We decided that the plan has to pay for the hospital observation services provided October 20 to October 21, 2019. We decided that the plan does not need to pay for the services provided October 22, 2019.
You asked the Plan to pay for the hospital observation services provided October 20 to October 22, 2019. You say that the services were medically necessary. The Plan says that coverage criteria was not met.
We decided that the plan has to pay for the hospital observation services provided October 20 to October 21, 2019.
Our physician reviewer found that the care plan outlined for the patient included observation for seizure activity and therapy services for ambulation. Observation for further seizure activity was medically necessary.
We also decided that the plan does not have to pay for hospital observation services provided October 22, 2019.
Review determined that the enrollee was stable following a period of 24 hours of seizure free observation, therapy services, and the completion of a neurology consultation. The enrollee was medically stable for discharge on October 21, 2019. Ongoing hospital care on October 22, 2019 was not medically necessary.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe roll-in shower provided on October 2, 2019.You asked the Plan to reimburse you forthe roll-in shower. You say that the roll-in shower is a necessity to your physical hygiene and is medically necessary.The Plan denied your request. The Plan says roll-in showers are not covered by Medicare or the Plan.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 hygienic, available to the general public,and would be helpful even to those who are not sick or injured. Also, Medicare does not cover home modifications.Therefore, we decided that the Plan does not have to reimburse you forthe roll-in shower provided on October 2, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to hold the enrollee harmless for the inpatient skilled nursing facility care (SNF) provided October 1, 2018 to October 4, 2018 and December 20, 2018 to January 1, 2019.
You asked the Plan to hold the enrollee harmless for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the services provided to the enrollee were not prior authorized. Services not authorized, unless emergent or urgently needed out of the area, are not a covered benefit.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for the SNF care by the provider. The provider is a contract provider. The file does not show that the plan provided notice that the SNF care would not be covered. Under Medicare rules, this means the SNF care is considered approved by the plan. Therefore, we decided that the Plan has to hold the enrollee harmless for the inpatient skilled nursing facility care (SNF) provided October 1, 2018 to October 4, 2018 and December 20, 2018 to January 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on December 19, 2019.
You asked the Plan to waive the copayment for an ambulance trip. You say that you cannot afford the charges. 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for ambulance services. You have been asked to pay a $250 copayment for an ambulance trip. An ambulance trip 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 an ambulance trip provided on December 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 8, 2018
to November 16, 2018.
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 the enrollee's
condition no longer required daily skilled services at an inpatient SNF level of care.
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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from November 8, 2018 to November 16,
2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (HCPCS G0249) provided to the enrollee from January 9, 2020 to January 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 per the review, the services were billed for 7, 14, 21, billing days, which are earlier than the required 25 billing days.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the CPT Code Manual definition of HCPCS code G0249 is "Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests."We find that HCPCS code G0249 is not supported in the medical record. Specifically,this code was billed on 7, 14, 21, billing days, which is less than the required 25 billing days. 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 laboratory services (HCPCS G0249) provided to the enrollee from January 9, 2020 to January 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided by an agency that does not participate in Medicare from October 3, 2019 to December 20, 2019.
You asked the Plan to pay for home health services. You say that you should be reimbursed for the services you paid for. The Plan denied your request. The Plan says services that were provided by a provider not enrolled in Medicare cannot be paid.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The provider you received these services from is not enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided by an agency that does not participate in Medicare from October 3, 2019 to December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PPE mask, arthritis gloves, forehead and ear thermometer (E1399 x 3), oximeter device (E0445) and gloves non-sterile (A4927).
You asked the Plan to pre-approve the items. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the durable medical equipment is not medically necessary.
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. Medicare does not cover equipment or supplies that are disposable (which means they can only be used once or a few times) unless they are needed as part of durable medical equipment. The masks, thermometer, gloves, and oxygen measuring device are not used to take care of a medical need (called an illness or injury). Therefore, we decided that the Plan does not have to pre-approve PPE mask, arthritis gloves, forehead and ear thermometer (E1399 x 3), oximeter device (E0445) and gloves non-sterile (A4927).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from December 18, 2019 to December 20, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says that that there was no medical necessity for formal hospitalization.
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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. The enrollee underwent a scheduled right heart cardiac catheterization as a pre-operative clearance process for a planned orthopedic procedure. The enrollee has a medical history significant for chronic obstructive pulmonary disease, diabetes mellitus, asthma, and reported exertional dyspnea for a 3-month duration. The enrollee was diagnosed with pulmonary artery hypertension and congestive heart failure. She was started on a continuous lasix infusion post procedure and had strict fluid monitoring for 48 hours. During this time, she was transitioned to oral diuretics, had a pulmonary consultation, and repeat laboratory studies. Care provided to the enrollee following the elective procedure was inpatient level. The drip required close monitoring and was not a routine component of right sided cardiac catheterization. While the enrollee remained stable throughout her hospital course, her care was more complex and required a two-night hospital stay. Inpatient care services are supported by the documentation. Our physician reviewer found that the enrollee's condition met Medicare criteria for acute 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from December 18, 2019 to December 20, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97350) provided on December 26, 2019.
You asked the Plan to pay for the therapeutic activities. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 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 therapeutic activities. Our reviewer says that CPT code 97530 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided does not include sufficient documentation to verify that CPT 97530 59 was a distinct and separate service, therefore this service cannot be verified. 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 therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities (97350) provided on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 00811 provided on December
9, 2019.
You asked the Plan to pay for the anesthesia 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 missing required information.
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 00811 is anesthesia for lower intestinal endoscopic
procedures, endoscope introduced distal to duodenum; not otherwise specified.
We find that CPT code 00811 is not supported in the medical record. Specifically, this code was billed without
a modifier indicating that the medical direction of qualified individuals for which an Anesthesiologist is
provided medical direction. When a claim is submitted by a CRNA or other qualifier individual rendering
anesthesia services, the Anesthesiologist is required to utilize the appropriate modifier indicating medical
direction was provided. Based on this information, we decided that Medicare rules for coverage of the
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the
anesthesia services coded 00811 provided on December 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing coded 81291 and 81479 provided on November 6, 2019.You asked the Plan to pay for the laboratory testing. 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 payable.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 81291 and 81479 are not supported in the medical record. Specifically, these codes were billed with the modifier GY. Modifier GY indicates non-covered charges and is not payable. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met.Therefore, we decided that the Plan does not have to pay for the laboratory testing coded 81291 and 81479 provided on November 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve microsurgical techniques requiring use of an operating
microscope (69990).
You asked the Plan to pre-approve microsurgical techniques requiring use of an operating microscope. You say
that this is medically necessary. The Plan denied your request. The Plan says this cannot be approved and paid
separately.
The Plan must follow Medicare rules. Medicare rules say that - microsurgical techniques requiring the use of
operating microscopes may be paid separately only when submitted with the CPT codes listed above.
We looked at the file and Medicare rules. The approved CPT codes, 63047 and 63048, are not included on the
list for which the requested procedure is separately payable. Based on this information, we decided that
Medicare rules for coverage of microsurgical techniques requiring use of an operating microscope have not
been met. Therefore, we decided that the Plan does not have to pre-approve microsurgical techniques requiring
use of an operating microscope (69990).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for stab phlebectomy of varicose veins provided on October 29, 2019.
You asked the Plan to waive the coinsurance for stab phlebectomy of varicose veins. You say that you should only owe a $150 copayment. 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received stab phlebectomy of varicose veins on October 29, 2019. Stab phlebectomy of varicose veins is considered an outpatient surgical procedure. The allowed amount is $2,614.58 and 20% of that is $522.92. You have been asked to pay the total coinsurance amount of $522.92 for stab phlebectomy of varicose veins. Stab phlebectomy of varicose veins 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 waive the coinsurance for stab phlebectomy of varicose veins provided on October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on February 2, 2016.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until December 30, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on February 2, 2016.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from August 6,
2019 to August 10, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically
necessary. The Plan denied your request. The Plan says that that there was no hemodynamic instability.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. The record
showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's
necessary hospital care (including earlier emergency department and/or observation care) would span two
midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for acute 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided to the enrollee from August 6, 2019 to August 10,
2019.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the provider is a participating provider with the Plan and asked the Plan to reconsider their denial. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 1, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.