Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the enrollee is receiving medically necessary acute care at the current hospital.
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 physician reviewer found that the enrollee was admitted to the acute care hospital in status epilepticus and was intubated. Blood cultures were positive for Staph aureus. A tracheostomy was placed. The enrollee has not weaned from the ventilator. It is documented that she responds to commands. LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that are materially different than those of short-term acute care hospitals. She is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. It is not clear that she is reasonably expected to benefit from, and improve with, LTACH services. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 LTACH admission is medically
necessary. The enrollee is stable and suitable for transfer to LTACH to continue vent weaning, tracheostomy
care, and physical, occupational and speech therapy. The Plan denied your request. The Plan says LTACH
admission is not medically necessary. There is no advantage in moving the enrollee from the current acute care
hospital to an LTACH. All services that would be provided in the LTACH are being provided in the current
acute care setting which is already approved.

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 that 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 acute care hospital where she 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 ECG provided on February 8, 2021.

You asked the Plan to waive the copayment for the ECG. You say that you should not have to pay the balance
for an exam required by the provider. You say that you don't believe this was coded correctly as EKG's are
covered testing on your policy. The Plan denied your request. The Plan says the claim reprocessed to only
apply a $75 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 $75 copayment for diagnostic procedures and tests, including ultrasounds, at all in-network locations of service. 

You have been asked to pay a $75 copayment for the ECG. The ECG falls 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 copayment for the ECG provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nail debridement (11720) and the office visit (99214) rendered by the out of network (OON) provider on November 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 the services were rendered by an out of network provider, without prior authorization.
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 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 nail debridement (11720) and the office visit (99214) rendered by the out of network (OON) provider on November 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EGD (CPT code 43235) provided on
February 6, 2020, at the outpatient department of the hospital.
You asked the Plan to waive the copayment for the EGD. You say that the endoscopist who performed the
procedure did not use the same sedation method as in previous endoscopy procedures and you were not given a
choice of what type of sedation to have used. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you had an EGD on February 6, 2020, performed at the outpatient department of
the hospital. You were asked to pay a $250 copayment for the EGD. Your 2020 EOC states that enrollees must
pay a $250 copayment for Medicare-covered surgery, provided in an outpatient hospital or an ambulatory
surgical center. 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 EGD (CPT code 43235) provided on
February 6, 2020, at the outpatient department of the hospital.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the vascular embolization procedure provided on November 9, 2020 billed with code 37242.
You asked the Plan to pay for the procedure as billed. You say that this service is supported and should be paid. The Plan denied your request. The Plan says the operative report does not describe this service.
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 37242 is vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms).
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the procedure as billed. Our reviewer says that the submitted documentation is not sufficient to support the reporting of code 37242. Our coding reviewer found the operative report does not support Vascular embolization or occlusion. Documentation does describe placement of an iliac artery occlusion device for which there is a more specific code to describe. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure as billed have not been met. Therefore, we decided that the Plan does not have to pay for the vascular embolization procedure provided on November 9, 2020 billed with code 37242.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on December 16, 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 procedure code 99284 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 99282 and 99284. The Plan allowed payment for code 99282. Code 99284 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on December 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ground mileage (A0425-DD) and the ambulance service, advanced life support, non-emergency transport (A0426-DD) provided on August 14, 2020.
You asked the Plan to pay for the transportation services. You say that the transportation services should be covered. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility for a scheduled appointment is not a Medicare covered benefit.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 transportation services. Our reviewer says that the transportation services are not medically necessary. Our physician reviewer found the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient on August 14, 2020. The reviewer found that the documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on August 14, 2020. The reviewer also found that the documentation did not support that the ambulance transport on August 14, 2020 was medically reasonable and necessary for the enrollee.
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 transportation services have not been met. Therefore, we decided that the Plan does not have to pay for ground mileage (A0425-DD) and the ambulance service, advanced life support, non-emergency transport (A0426-DD) provided on August 14, 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 you would like reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says you need LTACH to continue IV antibiotics, wound care, respiratory management and complex medical management.
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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for onabotulinumtoxina injection (CPT code J0585) provided on December 4, 2020.
You asked the Plan to waive the copayment for the medication. You say that you should only have a $40 specialist copayment and should not be charged for the medication you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received an onabotulinumtoxina injection (CPT code J0585) on October 2, 2020. You have been asked to pay 20% coinsurance of the allowed amount for prescription drugs. The allowed amount is $1,216. The total you owe is $243.20 ($1,216 x 20% = $243.20). 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 onabotulinumtoxina injection (CPT code J0585) provided on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on March 8, 2021, by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you received misinformation from your sales agent when you signed up for this Plan. You also say that you were told you could see this provider as long as you had a primary care physician (PCP). The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 (99213) provided on March 8, 2021, by an out of network (OON) provider.
Your complaint about potentially receiving misinformation from a Plan sales agent is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services (CPT 99214) provided to the enrollee on February 5, 2021.
You asked the Plan to pay for the services. You say that the Arizona Health Care Cost Containment System (AHCCCS) has established two telephonic code sets for provider use in order to deliver services to residents during the COVID-19 public health emergency. The Plan denied your request. The Plan says this was not billed with an appropriate date of service.
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 99214 is "office or other outpatient visit for the evaluation and management of an established patient." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the provider reported place of service 12 Home. Per Medicare "During the COVID-19 crisis, Medicare will pay the
non-facility amount for telehealth services when they are billed with the place of service (POS) the physician would have used if the service had been provided in person (e.g., POS 11 - Office)". The incorrect place of service was billed for this 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for office visit services (CPT 99214) provided to the enrollee on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (92004) and diagnostic imaging of an optic nerve (92133) provided on December 3, 2020, by an out of network (OON) provider.
You asked the Plan to pay for an office visit and diagnostic imaging. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-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. The records provided for review do not show that the services at issue were urgent or emergent. 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 (92004) and diagnostic imaging of an optic nerve (92133) provided on December 3, 2020, by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that that the enrollee is qualified for SNF care. The
Plan denied your request. The Plan says that the enrollee's needs are custodial/supportive in nature.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you have fluid retention and need continued care. The Plan denied your request. The Plan says your current needs can be met at a lower level of care.

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 services. Our physician reviewer found that the documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing needs. Your functional level does not require therapy services of a qualified therapist to safely and effectively provide treatment in a SNF. You do not require 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 skilled nursing facility setting. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) services.