Persius/hicric huggingface dataset:
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 these services are medically necessary. 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 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. 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 treatment of a tracheoesophageal fistula. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: 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 you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 required maximum assistance times two to sit up and lie down. The
enrollee has a wound vacuum in place. The documentation does not support that the enrollee requires an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not
support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be
met at 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 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 limited oral evaluation (D0140), and the unspecified preventive service (D1999) provided on July 27, 2020.
You asked the Plan to pay for the oral evaluation and unspecified preventive service. You say that you went to the dentist because you needed to get your teeth fixed. You say that you paid your portion for the services up front. You say that you received a bill for $1,602. You also say that you really needed a new upper denture as they do not last forever. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan also says that the unspecified preventive service 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 limited oral evaluation (D0140), and the unspecified preventive service (D1999) provided on July 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laminectomy (63047 and 63048) and incision and
drainage (22015) provided on April 30, 2020.
You asked the Plan to pay for the laminectomy and incision and drainage. 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 services 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 63047 is Laminectomy, facetectomy and foraminotomy
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or
lateral recess stenosis]), single vertebral segment; lumbar.
The CPT Code Manual definition of code 63048 is laminectomy, facetectomy and foraminotomy (unilateral or
bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess
stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in
addition to code for primary procedure).
The CPT Code Manual definition of code 22015 is incision and drainage, open, of deep abscess (subfascial),
posterior spine; lumbar, sacral, or lumbosacral.
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 laminectomy and incision and drainage. Our reviewer
says that CPT codes 63047, 63048 and 22015 do not meet criteria for billing or reimbursement consideration.
Our reviewer found the medical records submitted do not contain sufficient documentation to validate that
these services were rendered on the billed date of service.
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 laminectomy and incision and drainage have not been met. Therefore, we
decided that the Plan does not have to pay for the laminectomy (63047 and 63048) and incision and drainage
(22015) provided on April 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (10180) provided November 30, 2019.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 10180 is incision and drainage, complex, postoperative wound infection. We find that CPT code 10180 is not supported in the medical record. Specifically, the operative report does not document a procedure performed on complex postoperative infection. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (10180) provided November 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 28, 2020.
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 the testing is not covered.
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, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the upper endoscopy procedure (43248, 43239) provided on December 1, 2020.

You asked the Plan to reduce the copayment for the endoscopy procedure. You say that you should not be responsible for the full copayment because you believed this service was being provided in a physician's office and qualified as a physician's service rather than a surgical procedure. The Plan denied your request. The Plan says the service provided is classified as a surgical procedure and was provided in an ambulatory surgical center. Therefore, the copayment amount is correct.

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 $275 copayment for surgical services provided in an ambulatory surgical center. 

You have been asked to pay a $275 copayment for the endoscopy procedure. An endoscopy procedure (43248, 43239) is considered a surgical service and in this case provided at an ambulatory surgical center. 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 copayment for the upper endoscopy procedure (43248, 43239) provided on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewing radiographic images with dental code D0274 provided on October 8, 2020.
You asked the Plan to pay for dental code D0274. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D0274 is not covered under the Plan's supplemental dental benefit.
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, dental code D0274 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for bitewing radiographic images with dental code D0274 provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and the unspecified preventive
procedure (D1999) provided on September 8, 2020, and September 15, 2020.

You asked the Plan to pay 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 these services are not a covered benefit under
your dental policy.

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 services provided are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic
x-ray (D0330) and the unspecified preventive procedure (D1999) provided on September 8, 2020, and
September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wheeled folding walker.
You asked the Plan to waive the coinsurance for the wheeled folding walker. You say that you were not informed you would be charged for the walker. The Plan denied your request. The Plan says a folding walker wheeled services was rendered; therefore, you pay a 20% coinsurance for the covered item.
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 durable medical equipment. The total cost of the wheeled folding walker was $99.00. You have been asked to pay 20% coinsurance of $19.80 (20% of $99.00 = $19.80) for the wheeled folding walker. The wheeled folding walker falls within the durable medical equipment 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 the wheeled folding walker.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on June 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the rendering skilled nursing facility is also out-of-network.
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 podiatry services provided on June 30, 2020 by an out of network (OON) provider.
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 these services are medically necessary. The Plan
denied your request. The Plan says that inpatient rehab level of intensive therapy exceeds member's need.
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. 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 right sided
hemiparesis and was treated for a stroke. The enrollee's medical conditions are stable. There are no medical
needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need
for an intensive rehabilitation program. 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: Partially Favorable

We decided that the Plan has to reduce the copayment for the outpatient clinic visits. We decided that the Plan does not have to waive or reduce the copayment for the wound debridement services.
You asked the Plan to waive the copayment for the wound debridement services and outpatient clinic visits. You say that you have had these services earlier in the year and never had to pay a copayment. The Plan says that outpatient surgery services and outpatient observation services are each subject to a $600 copayment.
We decided that the Plan has to reduce the copayment for the outpatient clinic visits.
The Plan has assessed a $127.58 copayment for each of the outpatient clinic visits (G0463) provided from September 10, 2020 to October 22, 2020. The Plan reached this decision by applying the cost-sharing amount from the outpatient hospital observation benefit category. This allows for a copayment of $600, but the Plan's allowed amount for this service was $127.58 each time, so you were asked to pay the full allowed amount because it is less than the required copayment.
However, we determined that billing code G0463 is not coded as an observation or evaluation service. Instead, it is listed as a hospital outpatient clinic visit. Because it is unclear from the record if you met with a specialist or a primary care provider, it is our decision that the Plan should reduce the copayment to the lesser $15 copayment for an outpatient clinic visit provided by a primary care provider.
We also decided that the Plan does not have to waive or reduce the copayment for the wound debridement services.
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 $600 copayment for outpatient surgery and a for the outpatient clinic visit. Wound debridement services are considered a surgical procedure. Because the Plan's allowed amount was less than $600, you have been asked to pay the full allowed amount because it is less than your required copayment. Therefore, we decided that the Plan does not have to reduce the copayment for the wound debridement services.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services (99239).

You asked the Plan to pay for the hospital discharge day management services. You say that the medical records provided will show proof of medical necessity. 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 member's terminal condition until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services (99239).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on October 27, 2020.

You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says that members must receive medical care from a network provider. In most cases, care received from an out-of-network provider will not be covered. If the medical care that Medicare requires our Plan to cover and the providers in our network cannot provide, the member may get this care from an out-of-network provider. The member or the PCP, must obtain authorization from the Plan prior to seeking care.

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 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 nurse practitioner services provided on October 27, 2020.