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 has minimal support at home. You say that the enrollee needs to work on his endurance, as he has steps at home and therapy has not worked. You say that the enrollee is ready to be discharged from the hospital. 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 could 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 minimally invasive mitral valve replacement. 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: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for the general health panel (80050) provided on January 9, 2020.
You asked the Plan to hold you harmless for the general health panel. You say that you would like reconsideration because you had an annual wellness visit and should not be billed for laboratory services. The Plan denied your request. The Plan says that CPT code 80050 is not covered or paid for by Medicare.
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 general health panel by a contract provider. The file does not show that the Plan provided notice that the general health panel would not be covered. Under Medicare rules, this means the general health panel is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the general health panel (80050) provided on January 9, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the psychotherapy (CPT code 90837 x6) to be provided by a non-Medicare provider.
You asked the Plan to pre-approve the psychotherapy. You say that you received the directory that was really huge and hard to read to find a provider. You state you were seeing this provider and established a relationship with this counselor. The Plan denied your request. The Plan says this provider is not certified with Medicare.
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 the psychotherapy (CPT code 90837 x6) to be provided by a non-Medicare provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET and CT scan (CPT code 78815), for the enrollee.

You asked the Plan to pre-approve the PET scan. You say that the scan is necessary. The Plan denied your request. The Plan says the providers rationale is lacking and inadequate to support obtaining the PET scan based on Medicare and/or NCCN guidance.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 

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 PET scan. Our physician reviewer found the record indicates that the enrollee has a history of B-cell lymphoma. The record indicates that the enrollee has bone and joint pains, a nose-bleed, and felt a scrotal lesion. Laboratory results have not been provided. The record does not include notes from the oncologist whom the enrollee recently saw. The record does not indicate how the requested test was guide management and does not establish a working diagnosis. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET and CT scan (CPT code 78815), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (87186, 87150) provided on February 17, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.

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 87186 is "Susceptibility studies, antimicrobial agent;
microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multiantimicrobial,
per plate". The CPT Code Manual definition of code 87150 is "Culture, typing; identification by
nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed".

We asked our coding 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 services. Our reviewer says that the use
of codes 87186 and 87150 is not supported by the records provided. Our coding reviewer found that the
medical records provided do not include documentation of susceptibility studies per plate performed in an agar
solution to determine the minimum amount of antibiotic that is required to kill the bacteria, therefore code
87186 cannot be verified. The medical records provided do not include documentation of results to support
culture and typing by nucleic acid probe, therefore, this code 87150 cannot be verified.

We looked at this coder'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 pay for the services (87186, 87150) provided on February 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide (HHA) services up to 10 hours per week.
You asked the Plan to pre-approve the requested HHA services. You say that this is necessary for your health. The Plan denied your request. The Plan says criteria for these services are not met.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 HHA services. Our reviewer says that the documentation does not support that the enrollee requires skilled nursing or skilled therapy services, nor that HHA visits are medically necessary. Our physician reviewer found the member is a 72-year-old female with a medical history including diabetes mellitus, chronic heart disease and a history of falling who is requesting home health aide services for bathing, applying lotion and monitoring oxygen.
The documentation indicates that the member is at her baseline function and is able to ambulate with a walker. She requires assistance with self-care tasks but otherwise has been stable. She has been receiving home health nursing and should be independent with her disease management. There is no indication she is cognitively impaired. Her needs are custodial in nature. Based on this information, criteria for coverage of HHA services are not 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 the requested HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide (HHA) services up to 10 hours per week.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nephrology office visit provided on June 18, 2019.
You asked the Plan to waive the copayment for specialist visit. You say that you are not able to go back 2 years to research if you made payment the day of the appointment, so you do not feel you owe this amount. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $40 copayment for specialist visit. You have been asked to pay $40 copayment for specialist visit. Specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 nephrology office visit provided on June 18, 2019.
If the provider is billing you for charged beyond the applicable cost-sharing amount, please contact the Plan directly.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ER visit provided on January 6, 2019 and January 7, 2019.
You asked the Plan to pay for the ER visit. You say that this is not a hospice related claim and should be reprocessed. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
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 ER visit provided on January 6, 2019 and January 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fitness equipment purchased on August 30, 2020.
You asked the Plan to pay for the fitness equipment. You say that fitness equipment is covered by this benefit for the whole year. The Plan denied your request. The Plan says the fitness equipment was purchased before October 1, 2020, is not eligible for reimbursement under the Plan's health and wellness benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract for 2020 states that the Plan can pay up to $150 per calendar year toward your cost of a membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs, memory fitness activities, acupuncture and/or nutritional counseling. As of October 1, 2020, and until December 31, 2020, this benefit may also be used toward the purchase of exercise equipment that you can use at home. Purchases made prior to October 1, 2020, do not qualify.
The Plan's rules for coverage of gym benefits have not been met because this purchase was made prior to the Plan's policy changes that became effective on October 1, 2020. Therefore, we decided that the Plan does not have to pay for the fitness equipment purchased on August 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the 3-D CT scan of the heart provided on February 15, 2021.

You asked the Plan to waive the copayment for the CT scan. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 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 you received the 3-D CT scan of the heart on February 15, 2021. You were asked to pay a $195 copayment for the CT scan. Your 2021 EOC states that enrollees must pay a $195 copayment for all other diagnostic and nuclear medicine radiological services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 3-D CT scan of the heart provided on February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the flu vaccine provided on October 2, 2020 by an out-of-network provider.

You asked the Plan to pay for Influenza virus vaccine (90756) and administration (G0008). You say that the flu shot does not require pre-authorization. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network service.

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 services at issue in this appeal. The Plan did not pre-approve the services at 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 for the flu vaccine provided on October 2, 2020 by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating
provider on February 12, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you already paid a $25 copayment.
The Plan denied your request. The Plan says the correct copayment 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 $25
copayment for outpatient diagnostic tests/in-network/radiological diagnostic services.
You have been asked to pay a $25 copayment for an ultrasound. The correct copayment has been applied. An
ultrasound falls within the outpatient diagnostic tests/in-network/radiological diagnostic services 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 ultrasound provided by a participating provider on February 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response without transport provided on February 4, 2021.
You asked the Plan to pay for the ambulance response without transport. You say that you do not feel that you should be responsible for this amount since you felt you did the correct thing by not going to the hospital. The Plan denied your request. The Plan says ambulance services are not covered unless transportation is provided.
The Plan follows Medicare rules. Medicare rules say that ambulance services are only covered when the enrollee is transported. The COVID waiver allows for coverage of ambulance response without transport only in instances where transport would have been reasonable but did not occur due to COVID EMS protocols. 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 ambulance response without transport. Our reviewer says that the criteria for coverage under the COVID waiver are not met in this case. Our physician reviewer found the patient is a 90-year-old female who had experienced an episode of atrial fibrillation. The ambulance responded and found the patient with symptoms and vitals returned to normal. The patient decided not to go to the hospital as she was improving without intervention. Based on the above, the patient does not meet the treat-in-place COVID-19 protocols for ambulance services as no transportation services or emergency medical services were needed. 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 ambulance response without transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance response without transport provided on February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a general health panel (code 80050) provided to the enrollee on January 19, 2021.
You asked the Plan to pay for the panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not a payable code.
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code. You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for a general health panel (code 80050) provided to the enrollee on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic injections reported for date of service November 11, 2020, billed with codes 96372-XS and 96372-76-XS.
You asked the Plan to pay for the injections. You say that these services were medically necessary and
correctly billed. The Plan denied your request. The Plan says most of the codes billed were approved for
payment but 96372 is not payable.
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 96372 is Therapeutic, prophylactic, or diagnostic
injection (specify substance or drug); subcutaneous or intramuscular.
We find that CPT code 96372 is not supported in the medical record. Specifically, review of the record does
not reveal any reference to injections. Based on this information, we decided that Medicare rules for coverage
of the injections have not been met. Therefore, we decided that the Plan does not have to pay for the
therapeutic injections reported for date of service November 11, 2020, billed with codes 96372-XS and 96372-
76-XS.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0434) received August 8, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not have to pay for the second transportation to the in-network hospital. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $150 copayment for Ambulance Services.
You have been asked to pay a $150 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services 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 ambulance transportation (A0425, A0434) received August 8, 2020.
Appeal type: SNF
Decision: Unfavorable

You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are covered under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not need skilled medical care or skilled nursing care.
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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked 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 pay for SNF care provided to the enrollee from January 22, 2021, to February 20, 2021.