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 the enrollee was independent prior to hospitalization
and would like to return to that level. The Plan denied your request. The Plan says the denial of authorization
for IRF service is correct.
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 enrollee's nursing, medical, and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's
current medical status does not currently require intensive physician and nursing oversight only in an IRF.
While the enrollee may benefit from multiple therapies such as physical therapy and occupational therapy, the
documentation does not support that the enrollee's functional level requires an 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve4 additional physical therapy visits.You asked the Plan to pre-approve physical therapy visits. You say that the enrollee needs gait training to alleviate weakness.The Plan denied your request. The Plan says the enrollee has reached his therapy goals.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 physical therapy visits. Our physician reviewer found that the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. He has had extensive prior therapy and can participate in a home exercise program. He has made some progress in therapy, but the records do not indicate his functional level requires the ongoing unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve4 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient observation services provided from September 2, 2018 to September 4, 2018.
You asked the Plan to waive the copayment for the outpatient observation services. You say that you do not agree with the outpatient copayment. You say it should have been included with your hospital stay. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 a $400 copayment per stay for outpatient observation stays. You have been asked to pay a $400 copayment for the outpatient observation services. The outpatient observation services fall within the "Outpatient hospital services" benefit category. The medical record shows you were admitted under observation.
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 outpatient observation services provided from September 2, 2018 to September 4, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you confirmed that this provider accepted Medicare and were told that the cost to you would be $25 copayment. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 medical services provided on February 26, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for SNF care provided to the enrollee from January 1, 2020 through January 17, 2020.
You asked the Plan to waive the cost-share for SNF care. You say that you are appealing the enrollee's cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with the enrollee'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 show that the enrollee received SNF care from January 1, 2020 through January 17, 2020. For SNF care from December 10, 2019 through December 31, 2019 there was no cost-share due because the enrollee had met their 2019 maximum out-of-pocket. The enrollee's EOC states, the enrollee must pay $0 copay per day for days 1-20, then $178 copay per day for days 21-100. The enrollee's SNF care for January 1, 2020 through January 17, 2020 is a continuation of the SNF stay from December 10, 2019 through December 31, 2019. Therefore, the enrollee was asked to pay a $178 copayment for the 16 days (January 1, 2020 through January 16, 2020). The enrollee was not charged a copayment for the day of discharge January 17, 2020. The enrollee was asked to pay $2,503.06 which is less than the copayment for the 16 days of SNF care in 2020 because they met their Plan's 2020 maximum out-of-pocket. This means that the enrollee was asked to pay the correct amount based on the enrollee's contract with the Plan. This cost sharing is a contractual obligation the
enrollee agreed to pay when the enrollee enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-share for SNF care provided to the enrollee from January 1, 2020 through January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on March 18, 2019.
You asked the Plan to waive the copayment for the office visit. You say that the visit was for an annual routine physical exam. You say that you shouldn't have to pay the billed amount. 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 $25 copayment for services obtained from a primary care provider or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a primary care provider's office. You have been asked to pay a $25 copayment for the office visit. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The records show that you were treated for candidiasis of the skin and nail and osteoporosis during the office visit.
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 office visit provided on March 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown on tooth #9 for the enrollee.
You asked the Plan to pre-approve a crown. You say that the enrollee chipped her tooth and is very self-conscious about it. The Plan denied your request. The Plan says that this exceeds the allowable limits for this 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. The Plan covers a crown once per tooth per 60 months. We looked at the file and Medicare rules. The file indicates the enrollee received a crown on this tooth on April 5, 2018. Based on this information, we decided that the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #9 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transport mileage (A0170).You asked the Plan to pre-approvethe transport mileage. You say that the extended mileage is needed.The Plan denied your request. The Plan says the supplemental transportation benefit limits each one-way trip to 50 miles.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 24 one-way transport trips that do not exceed 50 miles each. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional routine transport mileage (A0170).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on February 19, 2020.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you have received this service in the past and have never been billed an additional fee. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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% of the cost for Part-B covered chemotherapy drugs and other Part-B covered drugs. You have been asked to pay $120.20 which is 20% of the allowed amount for the Part B injection. The allowed amount is $601. ($601 x 20% = $120.20). The Part B 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 coinsurance for the Part B injection provided on February 19, 2020.
Our decision is only about the 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on August 28, 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 procedure code 99292 is not supported.
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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). We find that CPT code 99292 is not supported in the medical record. Specifically, the records document a total of 40 minutes of critical care time; therefore, an additional 30 minutes of critical care beyond the initial 30 minutes is not supported. 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 pay for the critical care services rendered on August 28, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from June 19, 2019 through June 21, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.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 review indicates that 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 department (ED) 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 forthe acute inpatient hospital care provided from June 19, 2019 through June 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on an arthroplasty (27447)
provided by a Registered Nurse First Assistant (RNFA) on June 26, 2019.
You asked the Plan to pay for surgical assistant services. You say that this should be covered. The Plan denied
your request. The Plan says surgical assistant services are not covered from this type of provider.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on an
arthroplasty (27447) provided by a Registered Nurse First Assistant (RNFA) on June 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve day institute rehab services.
You asked the Plan to pre-approve the requested services. You say that the day institute program is a specialized program for individuals recovering from an acute injury or illness in an outpatient setting. The Plan denied your request. The Plan says comprehensive rehab therapy is not medically necessary. The enrollee can receive therapy in a standard outpatient setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 services. Our physician reviewer found that the enrollee is at contact guard assist for ambulating, minimal assist for gait trial, and at supervision for oral hygiene, upper body dressing, lower body dressing, and bathing. The requested day institute program is not medically reasonable and necessary above standard outpatient therapy service. The documentation does not reveal extenuating factors that support that the requested therapy at a day institute program is generally accepted as more specific and effective therapy for the enrollee's condition that a standard outpatient therapy program. The enrollee has met his speech therapy goals, and is at a high functional level in physical and occupational therapy. The enrollee may benefit from additional PT and OT in a standard outpatient therapy setting to solidify a home exercise program. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist only in the requested day institute 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve day institute rehab services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair, power seat elevation system and upgraded electronics.You asked the Plan to pre-approvea Group 3 power wheelchair (K0861), power seat elevation system and upgraded electronics. You say that you need a Group 3 power wheelchair, power seat elevation system and upgraded electronics.The Plan denied your request. The Plan says you do not require power tilt and power recline and the seat lift feature does not serve a primary medical purpose. The upgraded controller and harness cannot be covered as there is not a medical need to control the options through the joystick. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. A power seat elevation system is not covered by Medicare.There is only one seating system considered, therefore a Group 3 power wheelchair with upgraded electronics is not medically necessary.This means that Medicare rules for coverage of a Group 3 PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 3 power wheelchair, power seat elevation system and upgraded electronics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 30, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on November 19, 2019.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you were never in the hospital when you received this service. You say you were an outpatient and should be billed this way. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 a $340 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $340 copayment for the arthrocentesis.
You have been asked to pay a $230.09 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you were billed for your outpatient service by an outpatient hospital.
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 arthrocentesis provided on November 19, 2019.