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.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the IRF
admission is medically necessary. The Plan denied your request. The Plan says Ongoing skilled services can be
provided in an alternative setting such as home with Home Health Care, outpatient setting, or Skilled Nursing
Facility.
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
member does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. Our physician reviewer found the complexity of the
member's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the
enrollee from February 16, 2020 through February 19, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the extra day the enrollee
stayed was because they were not fed. The Plan denied your request. The Plan says the claim was processed
accordingly with the member's 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that the enrollee was admitted on February 16, 2020 and discharged on February 19,
2020. The enrollee was asked to pay a $380 copayment per day from February 16, 2020 through February 18,
2020, days 1-3 of the enrollee's inpatient hospital care. The enrollee was discharged on February 19, 2020 and
there was no copayment charge for the day of discharge. Per the enrollee's contract there is a $380 copayment
per day required for days 1-5. This means that the enrollee has been asked to pay the correct amount based on
the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient
hospital care provided to the enrollee from February 16, 2020 through February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99232) provided February 20,
2020.
You asked the Plan to pay for the subsequent hospital care. You say that please review the attached records for
medical necessity as the patient was seen on the same date by different provider/specialty/DX code; and
reprocess our claim for payment. The Plan denied your request. The Plan says services that are considered
column II procedures to another service are not eligible for reimbursement when billed with the column I
procedure code. Procedure code 99232 was denied as the column II code to the column I code 99221 and no
modifiers are allowed to unbundle these services.
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, we have confirmed that code the
subsequent hospital care has a bundled relationship with code 99221 and cannot be paid as billed. This code
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been
met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99232) provided
February 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided December 19, 2019 to December 22, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you respectfully disagree with the plan's determination and request review of the appeal and medical records and issue authorization for inpatient admission. The Plan denied your request. The Plan says the enrollee's signs, symptoms do not meet for acute inpatient stay. Care was consistent and meets medical necessity for observation care.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Care at the observation level appears to have been appropriate with the option to transition the enrollee to inpatient status if their condition warranted further hospital level 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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided December 19, 2019 to December 22, 2019.
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 services are medically necessary. The
Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee's
ongoing care needs include respiratory support including supplemental oxygen with intermittent BiPAP,
hemodialysis, close fluid balance, surveillance laboratory studies, and therapy services. The documentation
does not support that the enrollee in this case requires services at the LTACH that are not available at the acute
care hospital where he is currently receiving care. There are no required medical services identified that are
available at the LTACH, that are not available at the current health care setting being offered by the health
plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate
for the diagnosis and condition of the enrollee at this time.
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: 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 on the date of service you were shopping
with the enrollee when he began to experience a hypoglycemic event due to his low blood sugar levels. You
stated that paramedics were called for assistance and they administered treatment to the enrollee. The enrollee
began to be able to respond to questions and you say that the paramedics urged you take the enrollee to get
something to eat. You say that because the enrollee was cognizant and his sugar levels were at a comfortable
level, a trip to the hospital was not necessary. You asked the Plan to reconsider their denial and process the
services for payment. You say that the enrollee needed the medical services provided because it was an
emergency. However, you say that since it was resolved on site, a trip to the hospital would have resulted in
unnecessary medical costs. 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 December 16, 2019. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 5, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
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 physician's services provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered from December 23, 2019 to December
27, 2019.
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 provider is not Medicare-certified.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are
furnished by a provider or supplier enrolled in the Medicare program.
The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal.
Therefore, we decided that the Plan does not have to pay for the services rendered from December 23, 2019 to
December 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging.
You asked the Plan to pre-approve the myocardial perfusion imaging. You say that the records provided
support the need for the requested test. The Plan denied your request. The Plan says the medical records
provided do not support the need for the requested service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the myocardial perfusion imaging. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee has increased coronary risk but no symptoms of chest pain, no
abnormal cardiac exam and no ischemic electrocardiographic changes. In this circumstance documentation
does not support the medical necessity for nuclear stress testing. Screening nuclear stress testing has not been
shown to improve cardiac outcomes even in high risk patients. The has no known coronary disease, no
uninterpretable electrocardiogram, no LV dysfunction, no congestive heart failure and no concern for coronary
anomaly.
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 myocardial perfusion imaging have not been met. Therefore, we decided
that the Plan does not have to pre-approve myocardial perfusion imaging.
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 services are necessary. The Plan
denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 the enrollee is still receiving acute care at the current facility. They do not have
typical long term needs that would require LTACH or benefit from an LTACH setting. The enrollee will likely
be a candidate for a higher level of care than an LTACH at the time of discharge.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced pneumatic compression device (PCD). 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee's swelling cannot be treated with a basic pump. The Plan denied your request. The Plan says the enrollee has not tried and failed a basic lymphedema pump. 
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are only covered under certain medical indications. 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 requested device. Our physician reviewer found that the documentation does not support the enrollee has lymphedema extending onto the chest, trunk, or abdomen that extends past the limits of a standard compression sleeve; and the chest, trunk or abdominal lymphedema has failed to improve with a four-week trial. Therefore, the requested device is not medically reasonable and necessary at this time. 
 
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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced pneumatic compression device (PCD).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from July 19, 2019
through August 8, 2019.
You asked the Plan to waive the copayment for the SNF stay. You say that you were sent to rehab against your
will. You say that the cost isn't fair. The Plan denied your request. The Plan says the copayment applied
correctly.
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 $0
copayment per days for days 1-20 and a $172 copayment per day for days 21-100 for each Medicare-covered
SNF stays.
You have been asked to pay a $1,204 copayment for the SNF stay. ($172/day x 7 days = $1,204). The SNF stay
falls within the "Skilled nursing facility (SNF) care" benefit category. The records show that the SNF stay from
July 19, 2019 through July 31, 2019 applied SNF days 1-13 and the SNF stay provided from August 1, 2019
through August 8, 2019 applied SNF days 30-37. 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 SNF stay provided from July 19, 2019 through August 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Computed Tomography (CT) scan of the
abdomen and pelvis (74178) with a contrast injection (Q9967) provided February 24, 2020.
You asked the Plan to waive the coinsurance for the CT scan and contrast injection. You say that the
coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing was
applied.
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 20%
coinsurance for Diagnostic Imaging and Part B Drugs.
You have been asked to pay a 20% coinsurance for the CT scan and contrast injection. The CT scan falls within
the diagnostic imaging benefit category. The contrast injection falls within the Part B drug 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 a Computed Tomography (CT) scan of the abdomen and
pelvis (74178) with a contrast injection (Q9967) provided February 24, 2020.
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 reconsideration because the IRF
admission is medically necessary. The Plan denied your request. The Plan says there is no reason to think that
an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently
compared with therapy provided at a less intensive level
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 complexity of the member's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for canalith repositioning (95992) provided on July 12, 2019 through July 13, 2019.
You asked the Plan to pay for the canalith repositioning. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the required modifier information has not been billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 95992 is not supported in the record. Specifically, outpatient physical therapy codes are required to be billed with a GP modifier. CPT code 95992 has not been billed with the required modifier. Based on this information, we decided that Medicare rules for coverage of the canalith repositioning have not been met. Therefore, we decided that the Plan does not have to pay for canalith repositioning (95992) provided on July 12, 2019 through July 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has elevated prostate specific antigen (PSA) levels and presumed metastatic prostate cancer. The requested PET scan is not covered for initial treatment strategy for prostate cancer and is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.