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 need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 that you were admitted for an epidural hematoma and had multilevel laminectomy. You were transferred to inpatient rehabilitation from April 16, 2021, to May 14, 2021, and then transferred to skilled nursing facility, where you remain. Medical conditions 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. Although you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Fluid Flow.

You asked the Plan to pre-approve Fluid Flow. You say that Fluid Flow is the best course of treatment for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that Fluid Flow is helpful for treatment of the enrollee's condition.

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 Fluid Flow. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are insufficient high-quality studies to support the general use of Fluid Flow for the enrollee's condition and clinical scenario. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fluid Flow have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Fluid Flow.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), and gingival irrigation - per quadrant (D4921) provided January 11, 2021.
You asked the Plan to pay for the biological dressing, tooth extraction and gingival irrigation. You say that you expected the dental services to be covered. The Plan denied your request. The Plan says the services were rendered by a provider who has opted out of Medicare and therefore they aren't covered.
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 the biological dressing, tooth extraction and gingival irrigation when the services are medically necessary and reasonable. We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the biological dressing, tooth extraction and gingival irrigation have not been met. Therefore, we decided that the Plan does not have to pay for the placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), and gingival irrigation - per quadrant (D4921) provided January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (36415, 82248, 80053, 85007) provided on January 19, 2021, by an out of network (OON) provider.

You asked the Plan to pay for laboratory services. You say that the services were medically necessary, and authorization was obtained. The Plan denied your request. The Plan says services were provided 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 records provided for review also show that the enrollee was referred by a non-participating provider. 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 laboratory services (36415, 82248, 80053, 85007) provided on January 19, 2021, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections (64494, 64495) provided on January 24, 2020.

You asked the Plan to pay for facet joint injections. You say that this was billed correctly because these procedures were performed on two sides. The Plan denied your request. The Plan says one unit of each code should have been billed with a bilateral modifier.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT codes 64494 and 64495 is 1. The MAI value for this code is 2. You billed 2 units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint injections (64494, 64495) provided on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided by a participating provider on February 12, 2021, to April 9, 2021.
You asked the Plan to waive the copayment for physician services. You say that the doctor just called and told you that your medication was ready. The Plan denied your request. The Plan says the correct copayments have 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 $45 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay a $45 copayment for physician services. The total amount you are being asked to pay is $90 ($45 x 2 visits = $90). The correct copayment has been applied to the services that were provided.
Physician services fall within the physician/practitioner services/in-network/specialist 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 physician services provided by a participating provider on February 12, 2021, to April 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy for crisis (90839).
You asked the Plan to pay for the psychotherapy for crisis. You say that you would like this claim reprocessed
and approved for payment. The Plan denied your request. The Plan says this provider is not eligible for
reimbursement.
The Plan must follow Medicare rules. Medicare rules say that a licensed professional counselor is not eligible
for reimbursement.
We looked at the file and Medicare rules. In this case, the provider in question is a licensed professional
counselor and not eligible for reimbursement. Based on this information, we decided that Medicare rules for
coverage of the psychotherapy for crisis have not been met. Therefore, we decided that the Plan does not have
to pay for the psychotherapy for crisis (90839).
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 clinical information provided supports the need for IRF care. You say that the enrollee meets the criteria for coverage and will benefit from inpatient rehab that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the care needed in another setting.
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 was admitted for a fall with thoracic fracture requiring surgery. The enrollee's medical conditions 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a CT scan of the thorax (71250) provided on December 9, 2020.

You asked the Plan to waive the deductible for a CT of the thorax. You say that you were not fully informed about the charge for this service. 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. Your contract with the Plan says that there is a $750 deductible for advanced imaging services. 

The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for advanced imaging services. This cost sharing is a contractual obligation that had not been met at the time a CT of the thorax was received on December 9, 2020. Therefore, we decided that the Plan does not have to waive the deductible for a CT scan of the thorax (71250) provided on December 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81201, 81317, 81404, 81405, 81406,
81407, 81408, 81432) provided on January 14, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan
denied your request. The Plan says this was not billed with the correct POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81201, 81317, 81404, 81405, 81406, 81407, 81408, 81432) provided on January 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance services (A0428) provided on February 16, 2021.

You asked the Plan to waive the copayment for non-emergency ambulance services. You say that the enrollee should not be responsible for paying for the service. The Plan denied your request. The Plan says the copayment was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment for ambulance services. 

The enrollee has been asked to pay a $225 copayment for non-emergency ambulance services. The services at issue falls within the ambulance services benefit category. 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 non-emergency ambulance services (A0428) provided on February 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Denosumab 1 mg injection (J0897).

You asked the Plan to waive the copayment for Denosumab. You say that you believe this should be fully covered. The Plan denied your request. The Plan says the coinsurance processed correctly in this case.

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 Medicare Part B prescription drugs. 

You have been asked to pay a total cost share of $482.57 for Denosumab ($2412.84 Medicare-allowed amount x 20% coinsurance). Denosumab 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 Denosumab 1 mg injection (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1843).
You asked the Plan to pre-approve a knee orthosis. You say that this device is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says medical necessity criteria have not been met
for the requested equipment.
The Plan follows Medicare rules. Medicare rules say that the requested knee orthosis is subject to the criteria
listed 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 a knee orthosis. Our reviewer says that
this item is not medically necessary. Our physician reviewer found the requested knee orthosis is not medically
necessary as the documentation does not reveal evidence of objective knee instability on a physical
examination. There is also no evidence of a recent surgery or injury to the knees. The criteria for the L1843
have not been met
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a knee orthosis have not been met. Therefore, we decided that the Plan does not
have to pre-approve a knee orthosis (L1843).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on January 12, 2021.

You asked the Plan to pay for the therapeutic procedure. 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 supported by the documentation.

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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that the service was performed by a physical therapist assistant in a home health or hospice setting. There is a more appropriate code to be billed for these services. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for transitional care management services for problem of high complexity (99496) provided January 20, 2021.
You asked the Plan to waive the copayment for transitional care management services for problem of high complexity. You say that you would like the copayment you are being charged be waived. The Plan denied your request. The Plan says that you have been billed appropriately for the services you have received.
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 enrollees must pay a $0 copayment for physician/practitioner services. The Plan says you must pay a cost share of $100.23 for transitional care management services for problem of high complexity. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for transitional care management services for problem of high complexity. Therefore, we decided that the Plan has to waive the copayment for transitional care management services for problem of high complexity (99496) provided January 20, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided May 23, 2020.

You asked the Plan to waive the copayment for the emergency room visit. You say that you do not recall going to this facility and would like to appeal the copay for this visit. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $120 copayment for Medicare covered emergency room visits for Emergency care. 

You have been asked to pay $120 copayment for Medicare covered emergency room visits for the emergency room visit. the emergency room visit falls within the Emergency care 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 the emergency room visit provided May 23, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for Hepatitis C antibody screening (CPT code G0472) provided on March 4, 2021.

You asked the Plan to hold you harmless for the screening. You say that you believe this service was billed wrong as it is a high-risk reason why you are being screened for Hepatitis C regularly. The Plan denied your request. The Plan says that this service is not covered.

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 screening by a contract provider. The file does not show that the Plan provided notice that the screening would not be covered. Under Medicare rules, this means the screening is considered approved by the Plan. Furthermore, it appears that the plan's contracted delegate was provided the records for this service and has failed to forward them to support the decision to deny based on no medical necessity. Therefore, we decided that the Plan has to hold you harmless for Hepatitis C antibody screening (CPT code G0472) provided on March 4, 2021.

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.