Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forfoot orthotics.You asked the Plan to pay forfoot orthotics. You say that this orthotic would aid you in walking better with less trips to the doctor.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 pay forfoot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 5, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on August 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary. You say that the enrollee's needs cannot safely be met at a skilled nursing facility.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 care can be managed at a lower level.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs did not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status currently does not require intensive physician and nursing supervision in an IRF. The enrollee was to complete high dose steroids on January 21, 2021. Her blood pressure is controlled on a single agent. She is off oxygen and breathing normally with stable vital signs. While the enrollee may benefit from additional physical and occupational therapy the documentation does not support that she requires this therapy on an IRF level.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
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 IRF care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for IRF care have 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 above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, 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. Finally, 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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for interrogation device evaluation(s) (remote), up to 90 days
(93295 , 93296) provided July 13, 2020.
You asked the Plan to pay for remote interrogation device evaluation. You say that CPT codes 93295, 93296
and 93297 can be billed on the same date of service based on PTP Edit Rationale and no modifier is needed.
The Plan denied your request. The Plan says these CPT codes can only be reported once per 90 days.
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 93295 and 93296 are interrogation device evaluation(s)
(remote), up to 90 days, single, dual, or multiple lead implantable defibrillator system with interim analysis,
review(s) and report(s) by a physician or other qualified health care professional and interrogation device
evaluation(s) (remote), up to 90 days, single, dual, or multiple lead pacemaker system or implantable
defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical
support and distribution of results.
We find that CPT code 93295 and 93296 is not supported in the medical record. Specifically, the enrollee's
claims history indicates these services were provided on 04/17/2020 these CPT codes cannot be provided more
than once in a timeframe of 90 days. Based on this information, we decided that Medicare rules for coverage of
remote interrogation device evaluation have not been met. Therefore, we decided that the Plan does not have to
pay for interrogation device evaluation(s) (remote), up to 90 days (93295 , 93296) provided July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis the knee orthosis and suspension sleeve provided on July 17, 2020.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650), the knee orthosis (L1833) and suspension sleeve (L2397). You say that the Plan should pay this claim.The Plan denied your request. The Plan says they have insufficient documentation to corroborate the services to confirm Medicare coverage has been met.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 for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis the knee orthosis and suspension sleeve provided on July 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for CT scans and does not have to waive the
coinsurance for medical supplies provided on August 20, 2020.
You asked the Plan to waive the copayments for CT scans and to waive the coinsurance for medical supplies.
You say that you disagree with the charges because you should only owe a $50 copayment. The Plan denied
your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $50
copayment for each radiological diagnostic service and 20% coinsurance for medical supplies.
You received two CT scans on August 20, 2020. Therefore, you are responsible to pay a $50 copayment per
each CT scan. The total amount you owe for CT scans is $100.
You received medical supplies on August 20, 2020. The allowed amount is $12.00 and 20% of that is $2.40.
The total amount you owe is: $102.40.
You have been asked to pay the total amount of $102.40 for CT scans and medical supplies. CT scans and
medical supplies fall within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for CT scans and does not have to waive the
coinsurance for medical supplies provided on August 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forambulance services provided on June 24, 2020.You asked the Plan to waive the copayment forambulance services. You say that if you had been COVID-19 tested than you would not have required ambulance services.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $265 copayment for ambulance services. You have been asked to pay a $265 copayment for ambulance services. Ambulance services fall within the ambulance 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 forambulance services provided on June 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on August 13, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 physician services provided to the enrollee on August 13, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided by a participating provider on July 27, 2020, to July 28, 2020.You asked the Planto waive the copayment for emergency room services. You say that you were told you needed to be admitted. You say that you were then told you were kept under observation. You say that you wanted to go home. 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 $65 copayment for emergency care. You have been asked to pay a $65 copayment for emergency room services. The correct copayment has been applied to the services that were provided. Emergency room services falls within the emergency care 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 emergency room services provided by a participating provider on July 27, 2020, to July 28, 2020.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for encephalopathy, uncontrolled diabetes, acute kidney injury, and rib and lumbar fractures after a 
fall. 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. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the destruction of skin growths provided on September 14, 2020.
You asked the Plan to waive the deductible for the destruction of skin growths. You say that you went in for a spot on your nose and the doctor insisted on removing scabs. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the destruction of skin growths on September 14, 2020. The record shows that you had only paid $62.72 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $202.89. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time the destruction of skin growths were received on September 14, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the destruction of skin growths provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on October 2, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says denied because CPT code 99233 (Subsequent hospital care, per day, for the evaluation
and management of a patient) was billed on the same dates of service by different provider. Both providers are
within the same group and has the same specialty, which is Internal Medicine, which is considered the same
provider. Per CMS Claims Processing Manual, Chapter 12, Section 30.6.9 - A. "Both Initial Hospital Care
(CPT codes 99221 - 99223) and Subsequent Hospital Care codes are "per diem" services and may be reported
only once per day by the same physician or physicians of the same specialty from the same group practice,
whether the problems are related or not." Therefore, Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same
day to the same patient by the same physician or more than one physician in the same specialty in the same
group, only one service may be reported unless the evaluation and management services are for unrelated
problems. Based on the medical records provided, this claim cannot be paid as billed due to the physician
group relationship between the two providers. Medicare billing criteria were not met. Therefore, we decided
that the Plan does not have to pay for physician services provided to the enrollee on October 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forout-of-network lab services (stool test) provided to the enrollee on February 27, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out-of-network care.Medicare rules saythat 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 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 forout-of-network lab services (stool test) provided to the enrollee on February 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs HF System.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has NYHA Class III
congestive heart failure with reduced left ventricular ejection fraction (LVEF 35 to 40 percent) requiring
hospital admission. In this circumstance, therapy change based on data obtained from a CardioMEMs device
has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared
to standard medical therapy. The services are considered experimental in nature and are not reasonable or
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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a CardioMEMs HF System.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on August 3, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that your Plan should cover these charges.
The Plan denied your request. The Plan says this service is not covered under your plan.
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
periodontal maintenance provided on August 3, 2020.