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

We decided that the Plan has to pay for the acute inpatient hospital care provided January 8, 2020 to January 10, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary. The Plan denied your request. The Plan says that rules for coverage were not met.
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. Our physician reviewer found 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 and/or observation care) would span two midnights. 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 January 8, 2020 to January 10, 2020.
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 waive the coinsurance for the ostomy supplies provided on February 18, 2020.
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you never had coinsurance on the supplies before. The Plan denied your request. The Plan says you have been charged this coinsurance 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 20% coinsurance for Prosthetic devices and related supplies. You have been asked to pay 20% coinsurance for the ostomy supplies. The ostomy supplies fall within the Prosthetic devices and related supplies 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 ostomy supplies provided by on February 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that it is not safe to be home alone. You say that SNF care is needed in order to regain the ability to walk and function as before. The Plan denied your request. The Plan says the enrollee does not meet the qualifications for coverage of SNF care. The Plan says that ta maintenance program and prevention of deterioration can be met with intermittent skilled services.
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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is now mostly minimal assist to stand-by assist for all care. The enrollee has no complex wound care needs or IV medication requirements. There are no nursing or therapy needs that are skilled, which warrant a SNF as opposed to a lesser level of care. The enrollee's vital signs are stable and SNF care is not supported.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an airway clearing vest.
You asked the Plan to pre-approve the vest. You say that this is medically necessary. The Plan denied your request. The Plan says there is no qualifying diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 vest. Our reviewer says that the requested vest is not medically reasonable or necessary. Our physician reviewer found there is no qualifying diagnosis. There is inadequate evidence of benefit for this device in COPD. 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 vest have not been met. Therefore, we decided that the Plan does not have to pre-approve an airway clearing vest.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora central motor evoked potential study (95939 TC 59), somatosensory testing (95927 TC 59, 95938 TC 59) and needle electromyography (95861 TC 59, 95865 TC 59) provided on November 6, 2019.You asked the Plan to pay for the testing. You say that you would like reconsideration because you have no are not affiliated with the hospital and have no arrangement with the facility to receive reimbursement for your services.The Plan denied your request. The Plan says the member was an inpatient at the time the services were provided so place of service code 15 is inappropriate and the technical component of these services is not separately reimbursable.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Specifically, records indicate that this member was registered inpatient on this date of service. Medicare rules state that when a member is registered inpatient, place of service code 21 should be used irrespective of the setting where the services were actually rendered. Additionally, payment for the technical component of these services is included in the DRG payment to the facility and is the responsibility of the facility to any vendor.Therefore, we decided that the Plan does not have to pay fora central motor evoked potential study (95939 TC 59), somatosensory testing (95927 TC 59, 95938 TC 59) and needle electromyography (95861 TC 59, 95865 TC 59) provided on November 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 12, 2020 by an out of network (OON) provider.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 services were rendered by an out-of-network provider without 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 12, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Continuous Positive Air Pressure (CPAP) machine and related equipment (A4604, A7035, A7039, A7030) provided January 15, 2019 to March 15, 2019.You asked the Plan to waive the coinsurance for the CPAP machine. 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 Durable Medical Equipment. You have been asked to pay a 20% coinsurance for the CPAP machine. The CPAP machine 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 fora Continuous Positive Air Pressure (CPAP) machine and related equipment (A4604, A7035, A7039, A7030) provided January 15, 2019 to March 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 6, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 laboratory testing at issue in this appeal 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 provided on February 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.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 that the record does not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a skilled nursing facility. The member requires significant, ongoing assist for functional transfers and activities of daily living.A less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe arthrocentesis provided on February 10, 2020.You asked the Plan to waive the copayment forthe arthrocentesis. You say that this was a shot not surgery. You say that you shouldn't have to pay this.The Plandenied 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 Planclearly says that you must pay a $250 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay $237.93, which is less than the standard $250 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The arthrocentesis is considered a surgical procedure. This means that youhave 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 forthe arthrocentesis provided on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe molecular pathology services provided on November 20, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says the test is not covered for the diagnosis given.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 81406 is molecular pathology procedure, level 7.We find that CPT code 81406 is not supported in the medical record. In this case, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy.Based on this information, we decided that Medicare rules for coverage of the services provided have not been met.Therefore, we decided that the Plan does not have to pay forthe molecular pathology services provided on November 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forsurgical debridement services (11042) provided on January 20, 2020.You asked the Plan to waive the copayment forsurgical debridement services. You say that you previously did not have a copayment on this service.The Plan denied your request. The Plan says this service processed 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 $200 copayment for each visit for Medicare-covered outpatient surgery. You have been asked to pay a $200 copayment for surgical debridement services. 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 forsurgical debridement services (11042) provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe insertion or replacement of a leadless pacemaker (33274) provided on November 13, 2019.You asked the Plan to pay forthe leadless pacemaker services. You say that you would like reconsideration because this is the only CPT code for this service and no modifier is needed.The Plan denied your request. The Plan says charges for leadless pacemakers are not reimbursed unless the claim is submitted with a diagnosis code indicating participation in an approved clinical trial and modifier QO.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 33274 is not supported in the record. Specifically, codes for leadless pacemakers must be submitted with modifier QO to indicate that the service is being rendered as part of an approved clinical research study. Based on this information, we decided that Medicare rules for coverage of the leadless pacemaker services have not been met.Therefore, we decided that the Plan does not have to pay forthe insertion or replacement of a leadless pacemaker (33274) provided on November 13, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a tertiary level provider.
You asked the Plan to pre-approve these services. You say that you have contracted unnecessary viruses at local physicians. The Plan denied your request. The Plan says the tertiary level of care is not medically necessary.
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 these services. Our reviewer says that the tertiary level of care is not medically necessary. Our physician reviewer found the records show that the enrollee has complaints of abdominal pain but is otherwise healthy. A computed tomography (CT) scan revealed possible abnormality of the gallbladder. There is no medical indication to support the need to see a tertiary care surgical specialist at this time. The question of gallbladder disease is a common problem that can be evaluated by a non-tertiary provider. 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 referral to a tertiary level provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 7, 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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for an independent laboratory; however, the file shows that the specimen was obtained in an outpatient rehabilitation setting and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee is not medically appropriate for inpatient rehab.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 currently undergoing treatment at an ACH for a heart attack. The enrollee suffered a cardiac arrest and was intubated/ventilated. The enrollee subsequently received a tracheotomy. The enrollee is undergoing ventilator weaning and is tolerating sitting up and working with rehabilitative services. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient psychiatric facility for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansayscare can be received with a partial hospital program.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of May 18, 2020 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations,delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety.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 Plandoes not haveto pre-approveadmission to an inpatient psychiatric facility for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99215) and an electrocardiogram (93000) provided on December 12, 2019 by a provider that has opted out of Medicare.
You asked the Plan to pay for an office visit and an electrocardiogram. You say that you have out-of-network coverage. The Plan denied your request. The Plan says out-of-network coverage does not apply to providers who have 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 that has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for an office visit (99215) and an electrocardiogram (93000) provided on December 12, 2019.