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 requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee came to the hospital after a mechanical fall resulting in a right femur fracture on 1/9/20. She was transferred to a SNF for rehab. She was readmitted to acute care with acute hypoxic respiratory failure from influenza and pneumonia with septic shock and prolonged intubation. Hospital course complicated by dysphagia needing tube feeds, acute kidney injury leading to end stage renal disease and lower GI bleed. She was transferred to an LTACH on 2/27/20. She had persistent shortness of breath and cough. She went back to the acute care hospital for aspiration pneumonia on 3/10/20. PEG was placed on 3/12/20. She is taking oral intake and supplemented with PEG. She went to a SNF on 4/2/20. She is on 3-day weekly hemodialysis and has a sacral pressure ulcer. The enrollee's current level of function per pre-admission screen is moderate assist as of 4/10 for bed mobility, now can ambulate 50 feet with wheelchair.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 does not require the intensive physician or nursing oversight that is present in an IRF. The documentation does not reveal that her medical needs are unable to be met at her current setting. She may benefit from physical therapy and occupational therapy and likely participate in therapy but she is making gains in therapy in her current setting and given her decreased functional capacity as documented in therapy notes and her endurance level she does not require this therapy on an intensive IRF level 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 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 copayments forthe office visit, the x-ray, and the CAT scan from December 2, 2019 to December 16, 2019.You asked the Plan to waive the copayments forthe office visit, the x-ray, and the CAT scan. You say that you pay your monthly premiums and have met your deductible. You say you should not be charged for anything and insurance should cover every penny.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 $20 copayment for each in-network Medicare-covered visit with a PCP, a $35 copayment per day, per provider, for in-network Medicare-covered x-ray services after your yearly deductible is met, and a $150 copayment for each in-network Medicare-covered diagnostic radiology service afteryour yearly deductible is met. You have been asked to pay a $20 copayment for the office visit, a $35 copayment for the x-ray, and a $150 copayment for the CAT scan. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The x-ray and the CAT scan fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you had met your $250 in-network deductible amount.This means that you havebeen 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 copayments forthe office visit, the x-ray, and the CAT scan provided from December 2, 2019 to December 16, 2019.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 you required minimal assistance with grooming. You required moderate assistance to sit up, stand up, and transfer from bed to chair. You required maximum assistance with lower body dressing. The documentation does not support that you require fifteen hours per week of rehabilitative services and regular physician evaluation. You are currently limited by her weight-bearing status. Your care needs can be met at a lower level of care. 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: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on September 24, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered on September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on November 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 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 medical services provided to the enrollee by an out-of-network provider
on November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesiology services provided on July 31, 2019 by an out of network (OON) provider.You asked the Plan to pay for anesthesiology services. You say that these services were provided through the ER.The Plan denied your request. The Plan says these services were provided as outpatient. The Plan says that no prior authorization was 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 anesthesiology services provided on July 31, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveXolair.You asked the Plan to pre-approveXolair. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested drug is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Xolair. Our reviewer says that the documentation supports that the requested drug, Xolair is medically reasonable and necessary. Our physician reviewer found the enrollee has a history of severe persistent asthma. The enrollee had previously been treated with Qvar and Trelegy with persistent symptom. Then the enrollee was switched to Budesonide via nebulizer as well as Montelukast. The enrollee's symptoms of shortness of breath have continued in setting of elevated IgE. It would be medically appropriate to treat this enrollee with Xolair at this time given diagnosis of severe persistent asthma, significantly elevated IgE, and symptoms of persistent shortness of breath. The enrollee has not responded to conservative treatments and a biologic such as Xolair would be appropriate 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 Xolair have been met.Therefore, we decided that the Plan has to pre-approveXolair.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 12, 2019.You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that the benefit 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 $300 copayment for per one-way trip by ground or air ambulance. You have been asked to pay a $300 copayment for the ambulance transport. The ambulance transport falls within the per one-way trip by ground or air ambulance 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 transport provided on October 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the eye wear purchased August 12 2019.
You asked the Plan to reimburse you for eye wear purchased at the out-of-network provider. You say that the
out-of-network provider was much less than the in plan provider. The Plan denied your request. The Plan says
you did not purchase eye wear from the in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when you use the in-network provider.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the eye wear have not been met. Therefore, we decided that the Plan does not have to reimburse
you for the eye wear purchased on August 12 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9379) provided on November 22, 2019.
You asked the Plan to pay for home infusion therapy. You say that this was a necessary treatment. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9379 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9379) provided on November 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing coded 81240, 81241, 81291, 81400, 81401, 82955 provided on September 5, 2019.You asked the Plan to pay for the laboratory testing. 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.We find that CPT codes 81240, 81241, 81291, 81400, 81401, and 82955 are not supported in the medical record. Specifically, the documentation submitted did not include documentation of a complete order indicating the specific test that make up the comprehensive panel which supports the billed code; therefore,code 81240 cannot be verified. The documentation submitted did not include documentation of a complete order indicating the specific test that make up the comprehensive panel which supports the billed code; therefore,code 81241 cannot be verified. The documentation submitted did not include documentation of a complete order indicating the specific test that make up the comprehensive panel which supports the billed code; therefore,code 81291 cannot be verified.Current Procedural Terminology (CPT) code 81400 represents molecular pathology procedure level 1. The medical records indicate that gene analysis for TPMT was performed. There is a more appropriate Current Procedural Terminology (CPT) code that should be used to bill for the service provided.Current Procedural Terminology (CPT) code 81400 represents molecular pathology procedure level 1. The medical records indicate that gene analysis for DPYD was performed. There is a more appropriate Current Procedural Terminology (CPT) code that should be used to bill for the service provided. The documentation submitted did not include documentation of a complete order indicating the specific test that make up the comprehensive panel which supports the billed code; therefore,code 81401 cannot be verified. Current Procedural Terminology (CPT) code 82955 represents Glucose-6-phosphate dehydrogenase (G6PD); quantitative. The medical records do not show quantization was performed and indicate that a gene analysis of G6PD was performed to determine the risk of drug induced acute hemolytic anemia. There is a more appropriate Current Procedural Terminology (CPT) code that should be used to bill for the service provided.Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met.Therefore, we decided that the Plan does not have to pay for the laboratory testing coded 81240, 81241, 81291, 81400, 81401, 82955 provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care (99219) provided on October 29, 2019.
You asked the Plan to pay for the initial observation care. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says this service is included in another service that was rendered on the same date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99219 is not supported in the record. Specifically, another initial hospital care service was processed and paid for the same date of service. It is inappropriate to bill two initial care services for the same date of service. Based on this information, we decided that Medicare rules for coverage of the initial observation care have not been met. Therefore, we decided that the Plan does not have to pay for initial observation care (99219) provided on October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 23,
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 80047 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 80047 is basic metabolic panel (Calcium, ionized).
We find that CPT code 80047 is not supported in the medical record. Specifically, there is no documentation
that a basic metabolic panel was performed. 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
laboratory services rendered on October 23, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for therapeutic exercises (97110) provided on June 20, 2019.You asked the Plan to pay for the therapeutic exercises. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that this service was billed incorrectly.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan has not forwarded sufficient information to indicate why this service was billed incorrectly Therefore, we decided that the Plan has to pay for therapeutic exercises (97110) provided on June 20, 2019.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve the partial denture. You say that the partial denture is medically necessary.
The Plan denied your request. The Plan says the benefit for partial denture is limited to one every 60 months.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the benefit for partial dentures has
already been exhausted. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial
denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee from March 23, 2019, to September 27, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not certified for Medicare.
The Plan must follow Medicare rules. Medicare rules say that The rules state that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The requested provider is not enrolled in the Medicare program. 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 provided to the enrollee from March 23, 2019, to September 27, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 31, 2019.
You asked the Plan to pay for the SNF services. You say that this claim has been incorrectly denied. You are a valid provider and have been since 1994. The Plan denied your request. The Plan says the provider is ineligible. No valid Medicare ID was submitted by the provider and the provider is not showing as PPS exempt per the N Waiver Indicator and a termination date of 08/11/2016 is reflected.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 31, 2019.