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

We decided that the Plan does not have to pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Plan to pre-approveIRF care. You say that this is medically necessary.The Plan denied your request. The Plan says an intensive program with a team of health care professionals and doctors that specialize in rehab is not needed.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 wascorrect 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for total hipreplacement. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.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-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forDME and related supplies provided .You asked the Plan to waive the coinsurance forDME and related supplies. You say that you disagree with the charges because you did not order the second device and thought that it was part of the first.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for DME and related supplies. The record shows that you received DME and related supplies. The total allowed amount is $359.64 and 20% of that is $71.92. You have been asked to pay the total coinsurance amount of $71.82 for DME and related supplies. DME andrelated supplies fall within the DME 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 forDME and related supplies provided on
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF care.You asked the Plan to pre-approveSNF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care (ex. intermittent therapy, restorative nursing therapy, LTC).Welooked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveSNF care
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay formobile x-ray services (R0070) provided .You asked the Plan to pay forthe mobile x-ray services. You say that the services were not medically necessary.The Plan denied your request. The Plan says the claim was not filed correctly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code R0070 is not supported in the medical record. Specifically, the CPT code billed is listed as a Technical Component-only service in the National Physician Fee Schedule. This code is not eligible for separate payment when provided at the place of service billed. Based on this information, we decided that Medicare rules for coverage of the mobile x-rayservices have not been met.Therefore, we decided that the Plan does not have to pay formobile x-ray services (R0070) provided .
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Superion interspinous spacer (CPTcode(s) 22869 and 22870).You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says the services are considered experimental and investigational.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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spinous process spacer device is experimental. More research is needed to show safety and efficacy of the device.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Superion interspinous spacer (CPT code(s) 22869 and 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral for sclerotherapy and endovenous ablation therapy with an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is being denied for out-of-network when the provider is in-network.The Plandenied your request. The Plansaysthere are network providers available.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvea referral for sclerotherapy and endovenous ablation therapy with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe office visits.You asked the Plan to waive the deductible forthe office visits. You say that you could not reasonably obtain in-network coverage.The Plan denied your request. The Plan says you called the plan prior to services being rendered and were informed that the provider was out of network and required a deductible.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 a $1000 deductible for out of network services. The item or service you asked the Plan to waive the deductible for falls within the benefit category out of network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for out of network services. This cost sharing is a contractual obligationthat had not been met at the time of the office visits.Therefore, we decided that the Plan does not have to waive the deductible forthe office visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forcomplicated incision and drainage of an abscess (10061) provided .You asked the Plan to pay forthe surgical services. You say that your coding department has reviewed the claim and determined that it is coded correctly. Please reconsider for payment.The Plan denied your request. The Plan says the records do not support the service billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 10061 is incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia).We find that CPT code 10061 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia). Of note, there is a more appropriate CPT code, 10060, for the procedure performed. 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 forcomplicated incision and drainage of an abscess (10061) provided.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to hold you harmless forthe oxygen concentrator (E1390) provided .You asked the Plan to hold you harmless forthe oxygen concentrator. You say that you would like reconsideration because you were told you would be refunded, but the provider will not do that until they are paid by the Plan.The Plan denied your request. The Plan says that a corrected claim is needed before payment may be made.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were referred for the oxygen concentrator by a contract provider. The file does not show that the Plan provided notice that the oxygen concentrator would not be covered. Under Medicare rules, this means the oxygen concentrator is considered approved by the Plan.Therefore, we decided that the Plan has to hold you harmless forthe oxygen concentrator (E1390) provided on.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 toopen the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora routine venipuncture provided .You asked the Plan to pay forthe routine venipuncture. The Plan denied your request. The Plan saysthatin most cases care you receive from an out of network provider will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. Youor your PCPmust obtain authorization 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 servicesat 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 fora routine venipuncture provided
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea out-of-network referral for ambulatory surgery.You asked the Plan to pre-approvethe referral. You say that this is medically necessary.The Plan denied your request. The Plan says there are network providers available.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can providethe items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea out-of-network referral for ambulatory surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery and coinsurance for an injectionprovided by a participating provider.You asked the Plan to waive the copayment for an outpatient surgery and coinsurance for an injection. You say that you do not know why you are being charged additional charges.The Plan denied your request. The Plan says the correct copayment and coinsurance has been 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 $295 copayment for an outpatient surgery and a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a $295 copayment for an outpatient surgery and less than a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $486.07. You have been asked to pay $91.71 for an injection which is less than your coinsurance amount of $97.21 ($486.07 x 20% = $97.21). The total amount you are being asked to pay is $386.71 ($295 + $91.71 = $386.71). An outpatient surgery falls within the outpatient surgery benefit category and an injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery and coinsurance for an injectionprovided by a participating provider .
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay 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 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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has weakness after a stroke .The enrolleeis living at home and receiving home health services. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 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 enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.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-approveacute IRF admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a long-term acute care hospital (LTACH).You asked the Plan to pre-approvethe LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says care can be safely received in another setting, such as skilled nursing facility.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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. 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 she is currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. 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-approveadmission to a long-term acute care hospital (LTACH).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forradiology services provided  by an out of network (OON) provider.You asked the Plan to pay forradiology 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 referring provider 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 forradiology services provided  by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician's services provided.You asked the Plan to pay forthe physician's services. The Plan denied your request. 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 Plansays that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 physician's services. 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 forphysician's services provided
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay 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 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 consideredmedically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for diarrhea. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.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-approveacute IRF admission and services.