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

We decided that the Plan has to pay for the initial hospital care for evaluation and management of the enrollee (99223) provided on April 6, 2021.
You asked the Plan to pay for code 99223. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are bundled as part of the global surgical fee that was billed under a different claim by the same provider.
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 looked at the file and Medicare rules. Medicare rules say that the initial consultation or evaluation of the problem by the surgeon to determine the need for surgery is not included in the Global Surgical Package and may be paid for separately. This policy only applies to major surgical procedures. In this case, the file shows that the initial consultation or evaluation of the enrollee's problem by the surgeon to determine the need for surgery should not be included in the Global Surgical Package as the enrollee received a laparoscopic appendectomy, which is considered a major surgical procedure. Code 99223 should be billed separately and is payable as billed in this case. Therefore, we decided that the Plan has to pay for the initial hospital care for evaluation and management of the enrollee (99223) provided on April 6, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric hospital admission from September
14, 2020 through November 19, 2020.
You asked the Plan to pay for the inpatient psychiatric hospital admission. You say that the enrollee was
admitted for psychoses. Based on this information, as well as the documentation in the medical record, the
services were medically necessary. The Plan denied your request. The Plan says the submitted medical records
did not support the medical necessity required to approve an inpatient level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 an inpatient psychiatric hospital admission.
Our reviewer says that the inpatient psychiatric hospital stay was not medically necessary. Our physician
reviewer found that based upon review of the records provided, it was not expected this enrollee would
improve in a reasonable period of time as the information was not provided showing the contrary. The health
plan's denial of inpatient psychiatric services appears appropriate based on the documentation. This enrollee
did not appear to require inpatient mental health treatment based on the documentation presented. It did not
appear that active treatment was taking place based on the little documentation presented. It did not appear that
the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. This
enrollee was treated under an individualized treatment plan found in the record. It did appear that the records
were supervised and evaluated by a physician. Based upon review the records provided for the admission of
this enrollee does not meet criteria for acute inpatient mental health treatment as the documentation only
presents orders and there is no clear indication as to why this enrollee was in the hospital.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an inpatient psychiatric hospital admission have not been met. Therefore, we
decided that the Plan does not have to pay for the inpatient psychiatric hospital admission from September 14,
2020 through November 19, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide services rendered from September 2, 2019 to October 4, 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 2100 units of code G0156 are 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 G0156 is services of home health/hospice aide in home health or hospice settings, each 15 minutes. 

We find that CPT code G0156 is not supported in the medical record. Specifically, there is no documentation of note and time spent rendering the services. 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 home health aide services rendered from September 2, 2019 to October 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you need continued care for your knee and to continue with your therapy, so you do not lose your leg. The Plan denied your request. The Plan says the stay is not medically necessary.
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 daily skilled services are not necessary. Our physician reviewer found the documentation does not reveal evidence of skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your ultrasound and duplex of the right lower extremity (RLE) reveal no acute findings. The documentation did not include evidence that your functional level required skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation did not indicate that you needed skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a SNF setting. The documentation did not indicate a need for a transfer to a SNF or that your medical needs are not currently being 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G power upper extremity brace.
You asked the Plan to pre-approve the MyoPro Motion G brace. You say that this is medically necessary as other treatments have not been successful. The Plan denied your request. The Plan says clinical value and effectiveness have not been demonstrated in the peer-reviewed literature.
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 the MyoPro Motion G brace. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and Botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.
The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 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 MyoPro Motion G brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G power upper extremity brace.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy services provided on February 12, 2020.
You asked the Plan to waive the coinsurance for the chemotherapy services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received chemotherapy services on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received chemotherapy
services on February 12, 2020. You have been asked to pay a 20% coinsurance for the chemotherapy services,
totaling $1798.90. The chemotherapy services fall within the Medicare Part B prescription drugs benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the coinsurance for the chemotherapy services provided on
February 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis (31541) provided on October 26, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment was applied correctly to the service provided.
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 $350 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital.
You have been asked to pay a $350 copayment for the outpatient surgery provided. 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 Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis (31541) provided on October 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from
February 6, 2021, through February 28, 2021.
You asked the Plan to pay for the SNF services. You say that it is felt that Medicare payment should be made
for these dates. The Plan denied your request. The Plan says the enrollee remained with skilled needs until
February 5, 2021. Payment is approved for these dates. Beyond this time, care was custodial and noncovered.
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 the SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee did not have documented
skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were
not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The
enrollee's care needs at this point were custodial and, as a practical matter, could be provided 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 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 from February 6, 2021, through
February 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Breztri Aerosphere.
You asked the Plan to pre-approve Breztri Aerosphere. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Breztri Aerosphere.
Benefits for Breztri Aerosphere may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management service coded 99396 provided on March 9, 2021.

You asked the Plan to pay for the periodic comprehensive preventive medicine reevaluation and management service. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services must be submitted to the enrollee's primary insurer.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the periodic comprehensive preventive medicine reevaluation and management service until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management service coded 99396 provided on March 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, chest (71046) provided on April 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the diagnostic services. You say that you treated this enrollee in good faith and abased on medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 radiologic examination, chest (71046) provided on April 7, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) thorax (71250) provided February 26, 2021.

You asked the Plan to pay for the CT scan. You say that your primary doctor's office says you did not need an authorization and now you are getting billed for something that you should not be billed for. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.

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 computed tomography (CT) thorax (71250) provided February 26, 2021.
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 the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide routine transportation to physical therapy appointments.

You asked the Plan to provide routine transportation. You say that you need transportation for your upcoming physical therapy appointments. The Plan denied your request. The Plan says non-ambulance, non-emergency routine transportation is not covered under your plan benefits.

The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide routine transportation to physical therapy appointments.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on March 3, 2021 and 
March 4, 2021. 
 
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says self-
administered drugs are not covered under Part B. 

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on March 3, 2021 and March 4, 2021.