Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to receive rehabilitation in an inpatient rehab setting. The Plan denied your request. The Plan says this request 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 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. Our reviewer found that 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Our physician reviewer also found that 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent observation care services (CPT 99226) provided to the enrollee on August 31, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was denied because the claim was billed a place of service (22) outpatient.
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 99226 is "Subsequent observation care, per day, for the evaluation and management of a patient." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the medical records and claims history submitted indicate the patient was inpatient at the time these services were provided, therefore 99226 is not eligible for reimbursement consideration because it was billed as an outpatient visit. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for subsequent observation care services (CPT 99226) provided to the enrollee on August 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgery to partially remove the pancreas (48150).
You asked the Plan to pre-approve a partial removal of pancreas. You say that a mass found in your abdomen requires immediate surgery. The Plan denied your request. The Plan says there is insufficient documentation of diagnosis in the case record.
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 a partial removal of pancreas. Our reviewer says that the requested items/services cannot be determined at this time to be medically reasonable and necessary in this case. Our physician reviewer found that without clinical information we cannot assess the need for surgery. 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 partial removal of pancreas have not been met. Therefore, we decided that the Plan does not have to pre-approve a surgery to partially remove the pancreas (48150).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you believe that LTACH would be a better setting for you. The Plan denied your request. The Plan says there are no services available at the LTACH that are not available in your current facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is a 74 year old female who was admitted to the current acute care hospital with acute respiratory failure related to COVID-19. She required BiPAP, convalescent plasma, remdesivir, steroids, and antibiotics. She was also diagnosed with and treated for new onset atrial fibrillation with RVR. Recent notes show that atrial fibrillation is now controlled and she is tolerating oxygen only during the day and BiPAP at night. The patient appears to be improving and is likely to only need short-term additional acute care services to further wean, which can be received at the current location. The patient does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered soon when weaning and other treatments have been completed. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost-share for the outpatient infusion services (96361, 96365, 96366) and drugs (J1572).

You asked the Plan to waive or reduce the cost-share for the outpatient infusion and drug services. You say that you were told you would only owe a $325 copayment for each of these services. The Plan denied your request. The Plan says outpatient surgery has a $325 copayment, as do the additional services that were provided with this procedure. Medicare Part B drugs also require 20% coinsurance.

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 $325 copayment for outpatient surgery or other services and a 20% coinsurance for Medicare Part B drugs.

You have been asked to pay a $325 copayment for the infusion services provided to you on each date of service. These services were provided at an outpatient hospital. Your bill may vary slightly depending on which infusion services were provided each day, but the total cost for the services amount to $325 per day ($215.34 + $109.66 = $325, $133.98 + $191.02 = $325). Therefore, you have been asked to pay the correct amount for the outpatient infusion services based on your contract with the Plan.

You were also asked to pay $437.89 for the drugs that were provided on each day of service. The Plan requires a 20% coinsurance for Medicare Part B drugs. The Plan's allowed amount for the drug services is $2,189.44 per day ($2,189.44 x 20% = $437.89). 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 or reduce the cost-share for the outpatient infusion services (96361, 96365, 96366) and drugs (J1572).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Care needs can be met at a lower level of care (ex. SNF/SAR).

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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts (L3020).
You asked the Plan to pre-approve foot inserts. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts (L3020).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient skilled nursing facility admission.

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 pre-approve SNF care. Our reviewer says that an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a skilled nursing facility. You do not have complex wound care or other skilled nursing need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a skilled nursing facility. Skilled nursing and skilled therapy services are not required on a daily basis or as a practical matter on an inpatient basis, in a skilled nursing facility setting. Your needs are currently being met in the inpatient rehabilitation facility and there are no extenuating factors that would require a transfer to a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services (99202, 9760259, S9088) provided on October 21, 2020.
You asked the Plan to waive the copayment for the urgent care. You say that you should only have a $30 copayment for all of the urgent care services, but the provider is billing you for $150 and some of your services are showing as non-covered. The Plan denied your request. The Plan says that the $30 copayment for the urgently needed services applied correctly. The Plan also states that two of the service codes (97602 and S9088) are incident to the first, approved code, but these services are not approved or covered.
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 $30 copayment for each Medicare-covered urgently needed care visit. You have been asked to pay a $30 copayment for the urgent care service that was approved by the Plan. The additional amount you were billed comes from the two services that are not covered by the Plan. The file did not contain medical records from the non-contracted provider in this case. Without medical records, we are unable to verify if the billed services (97602, S9088) are supported.
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 urgently needed services (99202, 9760259, S9088) provided on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring
(95940) and neuromuscular junction testing (95937).

You asked the Plan to pay for continuous intraoperative neurophysiology monitoring and neuromuscular
junction testing. You say that this is supported in the records. The Plan denied your request. The Plan says this
was not billed with the correct place of service.

The Plan must follow Medicare rules. Medicare rules say that if a mobile unit is serving an entity for which
another POS code already exists, providers should use the POS code for that entity.

We looked at the file and Medicare rules. Though these services were billed with POS 15 for a mobile unit, the
record shows that these services were provided serving an entity for which another POS code already exists.
Based on this information, we decided that Medicare rules for coverage of continuous intraoperative
neurophysiology monitoring and neuromuscular junction testing have not been met. Therefore, we decided that
the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (95940) and
neuromuscular junction testing (95937).
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for mitral valve replacement, tricuspid valve repair and atrial appendage repair. Your medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hearing screening, hearing aids and supplies to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a hearing screening, hearing aids and supplies to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says the services must be received from a participating provider. Therefore, coverage criteria are not 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 a hearing screening, hearing aids and supplies to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (HCPCS R0070) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service is inappropriate for the 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 HCPCS code R0070 is "Transportation of portable X-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen."

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 services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation submitted documents place of service 31 Skilled Nursing Facility (a facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital. The procedure was performed in a mobile unit. Place of service 15 (a facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services) would be a more appropriate code to report.

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 radiology services (HCPCS R0070) provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999), two periodontal scalings and root planings (D4341 x2), localized delivery of antimicrobial agents (D4381), and gingival irrigation (D4921) provided by an OON provider.

You asked the Plan to pay for the preventive procedure, scalings and planings, localized delivery of antimicrobial agents, and gingival irrigation. You say that these services were recommended by the hygienist. The Plan denied your request. The Plan says these services were rendered by an OON provider and are not covered. The Plan also says that you were presented with the proposed treatment plan which indicated that these services would not be 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The documentation also indicates that you are not being charged for the preventive procedure (D1999). Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999), two periodontal scalings and root planings (D4341 x2), localized delivery of antimicrobial agents (D4381), and gingival irrigation (D4921) provided by an OON provider.