Persius/hicric huggingface dataset:
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 transfer to an LTACH is medically necessary. 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Medicare criteria for transfer 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the sterile needles used during intraoperative neuromonitoring on October 6, 2020 billed with code A4215.
You asked the Plan to pay for the sterile needles. You say that these services should be paid in full. The Plan denied your request. The Plan says A4215 is not payable on this claim. Payment was approved for code 95937.
The Plan must follow Medicare rules. Medicare rules say that payment for items and non-physician services rendered to an inpatient are included in payment to the hospital. Sterile needles are not separately payable to a physician as these items are included in payment to the facility. Therefore, we decided that the Plan does not have to pay for the sterile needles used during intraoperative neuromonitoring on October 6, 2020 billed with code A4215.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
December 18, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.

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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the services provided by an out-of-network provider on
December 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the echocardiogram rendered on December 28, 2020.
You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the deductible was 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 there is $500 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the Medicare-covered radiological diagnostic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on December 28, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the echocardiogram rendered on December 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for selective catheter placement (36248) provided on November 16, 2020.

You asked the Plan to pay for the selective catheter placement. 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. 

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 selective catheter placement. Our reviewer says that CPT code 36248 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided does not include sufficient documentation to validated that a Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate) was performed on November 16, 2020. 

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 selective catheter placement have not been met. Therefore, we decided that the Plan does not have to pay for selective catheter placement (36248) provided on November 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift.

You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare, and there is no HCPCS code for this device.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.

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 lift. Our reviewer says that the requested lift is not medically reasonable or necessary. Our physician reviewer found the records do not document that the custom patient assist device is likely to effect improvement in your condition, or arrest or retard deterioration in your condition. The records indicate that you are "immobile due to multiple sclerosis progression." You do not have the ability to ambulate. The provided records do not clearly document that the requested custom patient assist device is medically necessary with no other options for transfers.

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 lift have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on December 18, 2020.
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided to you on December 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the cystourethroscopy (52000) provided on May 24, 2019.

You asked the Plan to waive the co-payment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payment has been applied correctly to the service provided.

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 $150 co-payment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $150 co-payment for the Medicare-covered outpatient surgery provided. 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 the cystourethroscopy (52000) provided on May 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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the member's needs cannot be met in a skilled nursing facility. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The patient was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the office visit provided on December 8, 2020 by an out of network provider.

You asked the Plan to reimburse you for the office visit. You say that you went to the out of network provider because you had an emergency due to throat and ear infection. The Plan denied your request. The Plan says you did not request prior authorization and there are 8 contracted Otolaryngology providers in your area.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to reimburse you for the office visit provided on December 8, 2020 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the 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.
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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for acute-on-chronic respiratory failure and end stage renal disease. The enrollee is not intubated/ventilated. The enrollee is noted to have a poor long-term prognosis. 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 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the 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.

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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for progressive renal failure and gastrointestinal bleeding. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains on a ventilator. It is unclear what ventilator weaning has been attempted. 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 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 long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that his is medically necessary. The Plan denied your request. The Plan says this request is considered to be custodial care.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 24, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered 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.
We looked at the file, the Plan's contract and Medicare rules. 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 HCPCS code must be submitted for the panel. If the laboratory assays genes
in serial, then the laboratory must submit claims for genes individually. The order by the treating clinician must
reflect whether the treating clinician is ordering a panel or single genes, and additionally, the patient's medical
record must reflect that the service billed was reasonable and necessary.
When more than two codes from this list are submitted for the same beneficiary on the same date of service, the
claims processing system will reject every code submitted after the first two services. However, if a lab runs
more than two distinct procedural services from this list on a single date of service, then the lab must use the 59
modifier with each additional service billed as an attestation that it is a distinct procedural service.
In this case, there were no medical records provided confirming that the labs were billed correctly. Therefore,
we decided that the Plan does not have to pay for the laboratory services provided on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Player Club Pass.
You asked the Plan to pay for the Player Club Pass. You say that the Player Club Pass is used primarily for utilizing the driving range. The Plan denied your request. The Plan says player's clubs are not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The Plan's rules for coverage of health and wellness benefits have not been met because player's club memberships are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the Player Club Pass.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the placement of breast localization device provided on December 16, 2020.
You asked the Plan to waive the copayment for the placement of breast localization device. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgery in an outpatient hospital facility on the date of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for Outpatient surgery provided in an outpatient hospital facility. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an outpatient surgical procedure, the placement of breast localization device, on December 16, 2020. You have been asked to pay a $400 copayment for the placement of breast localization device. The placement of breast localization device falls within the Outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the placement of breast localization device provided on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 27, 2020 by an out of network provider.
You asked the Plan to pay for the office visit. You say that you have received payment without authorization previously. The Plan denied your request. The Plan says you did not request prior authorization.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on November 27, 2020 by an out of network provider.