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 for the enrollee.

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 the enrollee can safely receive the services needed 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 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart failure, urinary tract infection, and encephalopathy. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided on October 19, 2018, through October 28, 2018.
You asked the Plan to pay for the inpatient services. You say that you would like reconsideration because you should be paid at the LTACH rate. The Plan denied your request. The Plan says coding guidance does not support the sepsis coding received.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. DRG 871 is defined as Septicemia or Severe Sepsis Without MV >96 Hours With MCC. In this case, you billed the services provided October 19, 2018, through October 28, 2018 with DRG 871. 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 inpatient services. Our reviewer says that the documentation does not support a primary diagnosis of sepsis. Our physician reviewer found based on the medical records provided the principle diagnosis for the long-term acute care hospital (LTACH) admission and care appears to be respiratory failure, with ventilator dependence and not sepsis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG 871. Therefore, we decided that the Plan does not have to pay for the inpatient services provided on October 19, 2018, through October 28, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on July 6, 2020 and November 9, 2020 by an out of network provider.
You asked the Plan to pay for the podiatry services. You say that the facility's podiatrist is out of network but the enrollee cannot leave the facility during the pandemic. The Plan denied your request. The Plan says you did not request prior authorization for the out of network services.
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 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 podiatry services provided on July 6, 2020 and November 9, 2020 by an out of network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on September 11, 2020.
You asked the Plan to pay for the emergency room services. You say that the claim has not been paid in full or under the terms of the contract for the services rendered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on September 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 12, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 12, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 12, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on September 27, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you did not see a doctor, they checked your blood pressure, and told you to go to the dermatologist. You say you should get your money back. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency Care" benefit category. The record shows you received services at your emergency room visit. 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 emergency room visit provided on September 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test provided on August 14,
2020.
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that prior to the services being
rendered you were advised that this provider was in-network. The Plan denied your request. The Plan says this
service is not 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. Therefore, we decided that the Plan does not have to pay for the
adjunctive pre-diagnostic test provided on August 14, 2020.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for ECG's and an X-ray. We decided that the Plan does not have to reduce the cost-sharing charges for ECG's and an X-ray to the amount you requested.

You asked the Plan to waive the cost-sharing charges for ECG's and an X-ray. You say that you did not request the procedure. The Plan says that the claims were processed correctly and you are being charged the correct amount.

We decided that the Plan has to reduce the cost-sharing charges for ECG's and an X-ray from $325 to $25.

The Plan contract says that you must pay a $25 copayment for outpatient diagnostic tests and a $0 copayment for X-rays.

The Plan says that you must pay a $325 copayment for ECGS's and an X-ray. However, according to the Plan contract you cannot be asked to pay more than a $25 copayment. Therefore, we decided that the Plan has to reduce the cost-sharing charges for ECG's and an X-ray from $325 to $25.

We also decided that the Plan does not have to reduce the cost-sharing charges for ECG's and an X-ray to the amount you requested.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for outpatient diagnostic tests. Therefore, we decided that the Plan does not have waive the $25 copayment for ECG's and an X-ray.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least 12 leads (93010).

You asked the Plan to pay for the electrocardiogram. You say that please see the attached medical records and reprocess according to medical necessity. The Plan denied your request. The Plan says the claim was received after the timely filing limitation.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the electrocardiogram was not filed. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least 12 leads (93010).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits (99211) provided from August 4, 2020,
through September 28, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under
your contractual policy or by Medicare.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the office visits (99211) provided from August 4, 2020, through
September 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from August 11, 2019, August 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until September 17, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided from August 11, 2019, August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L3960) provided September 24, 2020.
You asked the Plan to pay for the orthosis. You say that the item was medically necessary. The Plan denied your request. The Plan says the documentation does not support the items billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery. No itemized shipping receipt or tracking number was provided to determine what items were delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for an orthosis (L3960) provided September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assessment for prescription eye wear and bifocal fitting.
You asked the Plan to pay for the assessment for prescription eye wear and bifocal fitting. You say that the enrollee did not have any input in selecting their optometrist. The Plan denied your request. The Plan says the provider is not in-network and the enrollee was not referred by an in-network provider.
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 the assessment for prescription eye wear and bifocal fitting provided by an out of network (OON) provider.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for COVID-19. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 pay for hospital care provided from July 14, 2020, to July 15, 2020.
You asked the Plan to pay for hospital care. You say that this should be covered. The Plan denied your request.
The Plan says the enrollee had stabilized by 8:00 am on July 14, 2020.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 hospital care. Our reviewer says that the
criteria for coverage of these services has not been met. Our physician reviewer found the records indicate that
all inpatient care provided after 8:00 am on July 14, 2020, through July 15, 2020, was not needed on an
emergent basis. The enrollee was hemodynamically stable and appropriate for ambulance transport with
monitoring to a Plan facility. The enrollee was admitted to the non-Plan hospital in Stable condition in no
distress. The post-stabilization care services at the non-Plan facility after 8:00 am on July 14, 2020, through
July 15, 2020, were not medically necessary or reasonable. The treating physician did not document (in the
physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not
have to pay for hospital care provided from July 14, 2020, to July 15, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the initial comprehensive preventive medicine evaluation and management service (99387) provided on July 20, 2020.
You asked the Plan to hold you harmless for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that you have exhausted the allowable benefit for coverage of an additional wellness exam for the 2020 calendar year.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for this service by a contract provider. The file does not show that the Plan provided notice that this service would not be covered. Under Medicare rules, this means this service is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the initial comprehensive preventive medicine evaluation and management service (99387) provided on July 20, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (S9328) provided on May 8, 2020, through July 29, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9328 has a status indicator of I and 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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9328) provided on May 8, 2020, through July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown provided on October 6, 2020.
You asked the Plan to pay for the crown. You say that you needed your tooth to be fixed. The Plan denied your request. The Plan says payment has been issued to you for the Plan allotted amount due to being given misinformation. The Plan also says that no further reimbursement is due to you by the Plan for dental services.
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 record shows that prior to the service being rendered you contacted the Plan and were given misinformation. The Plan has reimbursed you the $750 that they told you was available at the time. Therefore, we decided that the Plan does not have to pay more for the crown provided on October 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 26, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until August 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 26, 2018.