Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99202), needle electromyography (95886), and nerve conduction studies (95911) provided on October 22, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for an OON office visit, needle electromyography, and nerve conduction studies. You say that these services are supported in the records. The Plan denied your request. The Plan says these 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 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 an office visit (99202), needle electromyography (95886), and nerve conduction studies (95911) provided on October 22, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. 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's needs can be met at a lower, less intensive level of care.

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 has a past medical history of diabetes, stroke, lung disease, obesity, schizoaffective disorder and depression and is living at home with weakness and trouble ambulating. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) provided on December 26, 2020.

You asked the Plan to pay for critical care. You say that you want the Plan to pay for the services. The Plan denied your request. The Plan says medical records were not received to support the services provided.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 99291 is not supported in the medical record. Specifically, medical records were not received to support the services provided. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) provided on December 26, 2020.
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 services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that 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 you continue to receive acute care services, and these have not been denied. The
medical record does not indicate that you require services that you are not currently receiving but that would be
available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service
cannot be recommended.

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: 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that 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 medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visual field exam with extended testing
(92083) received April 7, 2021.

You asked the Plan to waive the copayment for the visual field exam with extended testing. You say that the
physician office representative said that the service was covered, but now you are being charged a $5
copayment. The Plan denied your request. The Plan says the service is covered with a $5 copayment.

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 $5
copayment for each Medicare covered diagnostic test and procedure.

You have been asked to pay a $5 copayment for the visual field exam with extended testing. The visual field
exam with extended testing falls within the Medicare covered diagnostic tests and procedures 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 visual field exam with extended testing (92083) received
April 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy procedures (43239) provided February 11, 2021.

You asked the Plan to waive the copayment for the outpatient procedure. You say that you believe you should not have such a large bill. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $200 copay for outpatient hospital services. 

You have been asked to pay $200 copay for the outpatient procedure. The outpatient procedure falls within the Outpatient hospital 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 esophagogastroduodenoscopy procedures (43239) provided February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on February 22, 2021.

You asked the Plan to waive the copayment for a specialist office visit. You say that telehealth copayments should be waived because of covid-19. 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 $30 copayment for physician/practitioner services/in-network/specialist. 

You have been asked to pay a $30 copayment for a specialist office visit. The correct copayment has been applied to the telehealth services provided. A specialist office visit falls within the physician/practitioner services/in-network/specialist 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 specialist office visit provided by a participating provider on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for c (L1833, L2397) provided on October 31, 2020.

You asked the Plan to pay for a knee brace. You say that this is supported by the records. The Plan denied your request. The Plan says this was provided following an unsolicited phone call.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of a knee brace have not been met. Therefore, we decided that the Plan does not have to pay for c (L1833, L2397) provided on October 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 8, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid The Plan denied your request. The Plan says prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 lab work provided on February 8, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amount for the 2-surface white filling on a posterior tooth (D2392), and the 3-surface white filling on a posterior tooth (D2393) provided on March 27, 2021.

You asked the Plan to waive the cost share amount for the dental services. You say that you feel these services should be covered. You also say that your dentist advised that the plan covered 50% of the services. The Plan denied your request. The Plan says there is a 50% coinsurance for Class 2 Basic Services, including fillings.

The Plan says that if a method of treatment is more costly than is customarily provided, benefits will be paid on the least costly method of treatment. The Plan also says that you are responsible for the remaining balance.

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 and fillings are listed as covered, the 50% coinsurance was applied to the alternate benefit of the silver filling. The Evidence of Coverage clearly states that if a method of treatment is more costly than is customarily provided, benefits will be paid on the least costly method of treatment, and you will be responsible for the remaining balance. Therefore, we decided that the Plan does not have to waive the cost share amount for the 2-surface white filling on a posterior tooth (D2392), and the 3-surface white filling on a posterior tooth (D2393) provided on March 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 based on review of the available records, the enrollee does not meet CMS criteria for IRF admission for an uncomplicated hip fracture with post-op stability. The enrollee is medically stable with no evidence of need for supervision by a Physical Medicine and Rehabilitation (PMR) physician. She may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot plate pads (CPT code K0108), expandable
controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code
E2377) and harness for upgrade to expandable controller, including all fasteners, connectors and mounting
hardware, each (CPT code E2313).

You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your
request. The Plan says the items are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The upgraded electronics (expandable controller and electronic connector to 2 power options) are not medically
necessary. They are necessary when there is a medical need to control power options though the joystick. The
notes do not show a medical need to control the power options through the joystick. The power options can be
controlled using their own switches. These switches can be made any size without asking for a separate request.
They can be made from any material without asking for a separate request. All of this can be done without the
need to use the joystick to control the power features. The footplate pads do not serve a medical purpose.
Therefore, we decided that the Plan does not have to pre-approve foot plate pads (CPT code K0108),
expandable controller, including all related electronics and mounting hardware, upgrade provided at initial
issue (CPT code E2377) and harness for upgrade to expandable controller, including all fasteners, connectors
and mounting hardware, each (CPT code E2313).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 4, 2020.

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 the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid.

In this case, the MUE for CPT code 88321 is 1. You billed 4 units of this code, exceeding the MUE. 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 May 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide (HHA) for sixteen (16) hours per
day, seven (7) days per week (CPT code 99509), for the enrollee.

You asked the Plan to pre-approve the services. You say that the enrollee has a history of a mechanical fall in
2012 resulting in the enrollee becoming a complete paraplegic from the mid-thoracic region down. You state
the enrollee lives alone and relies on the very few hours approved for a home health aide. The Plan denied your
request. The Plan says the home health aide services you asked for are not being done for medical reasons or
helping with skilled nursing or therapy care.

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 services. Our physician reviewer
found the health plan's denial should be upheld. There is no evidence that the enrollee is receiving home health
(HH) registered nurse (RN) services or HH rehabilitative services.

Associated HHA services must be intermittent and provided in conjunction with HH RN or HH rehabilitative
services. As such, the documentation does not support that the requested HHA services are medically
necessary, reasonable or covered.

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 pre-approve a home health aide (HHA) for sixteen (16) hours per day, seven (7) days per week (CPT
code 99509), for the enrollee.
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 will benefit from a week or two (2) of short-term rehabilitation. 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 you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.