Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy visit.

You asked the Plan to waive the copayment for the physical therapy visit. You say that you should not be responsible for this copayment. 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 $35 copayment for each in-network Medicare-covered therapy visit.

You have been asked to pay a $35 copayment for the physical therapy visit. the physical therapy visit falls within the each in-network Medicare-covered therapy visit 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 a physical therapy visit.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76937) provided on May 10, 2020.

You asked the Plan to pay for an ultrasound. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with the necessary primary procedure.

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 76937 is ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure). 

We find that CPT code 76937 is not supported in the medical record. Specifically, this code was not billed with a primary procedure. Based on this information, we decided that Medicare rules for coverage of an ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76937) provided on May 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation.

You asked the Plan to waive the copayment for inpatient rehabilitation. You say that you feel that the enrollee should only owe one inpatient hospital copayment as the condition she was treated for never changed. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $150 copayment for days 1-5 for inpatient hospital care. 

The enrollee had an inpatient hospital stay. This is considered a new inpatient hospital admission. Therefore, the enrollee is responsible to pay a $150 copayment for days 1-5. $150 (copayment) x 5 (inpatient days) = $750.

The enrollee has been asked to pay the total copayment amount of $750 for inpatient rehabilitation. Inpatient rehabilitation falls within the inpatient hospital care 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 inpatient rehabilitation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee brace (L1833) provided on October 2, 2020.

You asked the Plan to pay for the knee brace. You say that you would like reconsideration because the knee
brace is medically necessary. The Plan denied your request. The Plan says there is no evidence of an
established relationship between the member and ordering provider.

The Plan follows 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 pay for the knee brace. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation does not reveal evidence of a recent injury or surgery to the left leg. The
documentation does not reveal evidence of an objective evaluation of the member's gait to indicate whether she
is currently still ambulatory as the documentation states that her pain makes it "difficult to move." The
documentation does not reveal evidence of an objective hands on exam by a treating medical provider. There is
no evidence of the degrees of laxity on an objective exam by a treating medical provider indicating evidence of
pathology.

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 knee brace have not been met. Therefore, we decided that the Plan does not
have to pay for the knee brace (L1833) provided on October 2, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve botox.

You asked the Plan to pre-approve botox. You say that the requested botox is medically necessary. The Plan denied your request. The Plan says the enrollee's clinical records must show that botox has been received by the enrollee in the past 365 days, and the enrollee must try and fail Dysport and Xeomin first.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 botox. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found based upon the clinical records received, medical necessity criteria were met. However, the Step Therapy is not met because clinical records did not show that the requested targeted product has been received by the enrollee in the past 365 days, and the enrollee has not tried and experienced a documented inadequate response or intolerable adverse event to any of the preferred products (Dysport, Xeomin). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of botox have not been met. Therefore, we decided that the Plan does not have to pre-approve botox.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 enrollee does not meet criteria for IRF admission. 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 knee pain and had surgical repair of quadriceps tendon rupture. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. 

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 21, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the hospital services. You say that you would like reconsideration because the services provided were medically necessary and rendered in good faith. The Plan denied your request. The Plan says prior 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 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 January 21, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says care needs can be provided for in a lower level of care setting.

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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of chronic medical problems. His physical function is at or near his baseline and he can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on April 18, 2020, through June 12, 2020.

You asked the Plan to pay for the home health services. You say that you would like reconsideration because the member was highly satisfied with these services and payment is a significant amount for a small Home Health Care company. The Plan denied your request. The Plan says Medicare rules for payment of these Home Health Skilled Nursing services billed on a professional CMS-1500 claim form have not been met.

The Plan must follow Medicare rules. Medicare rules say that providers are required to use the electronic HIPAA standard institutional claim transaction, the 837I. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, these services have not been billed on the appropriate 837I claim form. Therefore, we decided that the Plan does not have to pay for home health services provided on April 18, 2020, through June 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the member was forced to stay in the hospital due to their mental condition. You say the copayment is too high. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment per day for days 1-5 and $0 after day 5 each time you are admitted to an acute care hospital for inpatient hospital care.

The enrollee has been asked to pay a $275 copayment for each day of the inpatient hospital stay. ($275 x 3 days = $825). The inpatient hospital stay falls within the "Inpatient hospital care" 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 the inpatient hospital stay.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive nursing facility assessment provided on March 27, 2020.

You asked the Plan to pay for the evaluation and management service. You say that the medically necessary service was rendered to the enrollee in good faith. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says that it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the comprehensive nursing facility assessment provided on March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator for the enrollee.

You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that there is inadequate documentation that the requested device is being used as a delivered volume ventilator.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 home ventilator. Our reviewer says that a home ventilator is not medically reasonable and necessary for the enrollee. There is no evidence that the requested item, Lifeline 2000 ventilator, (E0466 device) is being used to deliver a set tidal volume. The unit delivers oxygen with nasal prongs-not a mask. There is inadequate documentation that the requested device is being used as a delivered volume ventilator. The patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a home ventilator.

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrodesis services coded 27279 provided.

You asked the Plan to pay for the arthrodesis services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 27279 is arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device. 

We find that CPT code 27279 is not supported in the medical record. Specifically, this code is a device procedure that was reported without a device HCPCS code on the claim required for that procedure. Based on this information, we decided that Medicare rules for coverage of the arthrodesis services have not been met. Therefore, we decided that the Plan does not have to pay for the arthrodesis services coded 27279 provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99213) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria has not been met.

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 Plan does not have to pre-approve office visits (99213) to be provided by an out of network (OON) provider.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the infrared heating pad system (E0221).

You asked the Plan to pay for the infrared heating pad system. You say that this service is necessary. The Plan denied your request. The Plan says this service is not covered.

The Plan must follow Medicare rules. Medicare rules say that there are no covered indications for infrared therapy devices. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare and the Plan do not cover infrared heating devices. Therefore, we decided that the Plan does not have to pay for the infrared heating pad system (E0221).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided by an out of network (OON) facility.

You asked the Plan to pay for the OON inpatient hospital care. You say that these services were medically necessary and this was the best facility at which to have the procedure. The Plan denied your request. The Plan says this was not an emergency admission. No authorization was requested to have these services provided 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 for the inpatient hospital care by an out of network (OON) facility.