Persius/hicric huggingface dataset:
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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for coronary artery bypass grafting. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.

You do 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 you 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) provided Nov 3, 2020 to Nov 24, 2020.

You asked the Plan to pay for the chiropractic services. You say that you have had 3 spinal fusions and that is the only code the chiropractor can use. You have had significant pain and limited movement in your neck since your surgeries and the spinal manipulations have helped you tremendously. The Plan denied your request. The Plan says this service cannot be covered when provided for the diagnosis reported.

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.

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 chiropractic services Our reviewer says that the Medicare criteria has not been met for the chiropractic services. Our physician reviewer found the provider billed services with diagnosis M99.01 - segmental and somatic dysfunction of cervical region. Therefore, this service is not 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 chiropractic services have not been met. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) provided Nov 3, 2020 to Nov 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the lumbar spine.

You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the requested MRI of the lumbar spine is medically necessary. The Plan denied your request. The Plan says the requested MRI of the lumbar spine is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.

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 an MRI of the lumbar spine. Our reviewer says that the requested MRI of the lumbar spine is not medically necessary. Our physician reviewer found the enrollee has a few weeks history of hip pain that was sudden in onset without apparent injury. There is limited pain with activity. Physical examination does not reveal any neurologic deficit and only mild pain is elicited with flexion and rotation of the hip. The enrollee has only taken Lyrica and has not done physical therapy. Plain films are reported to show arthritis of the hip and lumbar spine with foraminal narrowing at L4-L5 and L5-S1. The totality of the record does not support the medical necessity and reasonableness of the requested service in the enrollee's specific clinical scenario. The elements of the coverage rule 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 an MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the lumbar spine.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on March 17, 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 by the member's primary care physician.

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 March 17, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical assistant services on the application of a skin substitute graft (15274, 15273) provided on March 24, 2020.

You asked the Plan to pre-approve surgical assistant services. You say that this is supported in the records. The Plan denied your request. The Plan says surgical assistant services are not covered for these procedures.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 15274 and 15273. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical assistant services on the application of a skin substitute graft (15274, 15273) provided on March 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds (CPT code K0806).

You asked the Plan to pre-approve the DME. You say that you have limited leg mobility to get around and without the scooter you cannot perform day to day function. You state you do not have assistance in the home and being without mobility is causing your health to decline. The Plan denied your request. The Plan says DME for usage not needed in the home is not covered.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 DME. Our physician reviewer found there is documentation that you have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. There is documentation that your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair due to your level of weakness and instability. You can safely operate a power mobility device but the requested three-wheel electric scooter (power operated vehicle, group 2 standard) has capabilities that do not make it desirable for primary use in the home. The health plan has stated that consideration would be given to an alternative power operated vehicle or wheelchair that is more suited to in-home use. 

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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds (CPT code K0806).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861) and power seat elevation system (CPT code E2300).

You asked the Plan to pre-approve the DME. You say that you have been diagnosed with Sporadic Inclusion Body Myositis (SIBM) a crippling degenerative muscular disease, so you should be able to receive a power wheelchair with all of the outlined features recommended by your physiatrist and physical therapist. The Plan denied your request. The Plan says you do meet the criteria for coverage of a power tilt feature and a group three wheelchair with single power options; however, you do not meet the coverage for the power wheelchair, group 3 standard, multiple power options. The Plan states the power seat elevation system is not covered.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 DME. Our physician reviewer found there is documentation that you have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. Based on the medical records provided there is documentation that your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair due to your level of weakness and instability. There is documentation that you can safely operate a power mobility device but criteria are not met for the requested group 3 power wheelchair with multiple power option as there is no need for other powered options besides the power tilt that has been approved with the group 3 power wheelchair with single power option. Furthermore, the rules say that a power seat elevation feature (E2300) is non-covered because it is not primarily medical in nature.

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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861) and power seat elevation system (CPT code E2300).
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 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 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 weakness and a fall. Medical conditions are stable. 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. The patient 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam, refraction and ophthalmic imaging provided on August 31, 2020.

You asked the Plan to pay for the eye exam, refraction and ophthalmic imaging. You say that the patient thought they had this insurance only for prescriptions. You say that you are not in-network, but payment should be considered upon these unusual circumstances. The Plan denied your request. The Plan says prior authorization was required but 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 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 eye exam, refraction and ophthalmic imaging provided on August 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of Coflex lumbar interspinous decompression device.

You asked the Plan to pre-approve these services. You say that you would like to avoid having a fusion. The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by Medicare.

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 requested services are not considered medically reasonable and necessary in this case. The Coflex device is experimental. More research is needed to show safety and efficacy. High failure rates have been reported with similar devices. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of Coflex lumbar interspinous decompression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis provided on September 20, 2020.

You asked the Plan to pay for the knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf (L1833RT). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the enrollee's medical condition to support the medial necessity for the billed supply code.

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 physician order or relevant medical records which support medical necessity for the supplies provided in this case. There is no physician order or medical records in the case file for the knee orthosis. 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 the knee orthosis provided on September 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for genetic testing provided by a participating provider on August 12, 2020.
You asked the Plan to waive the coinsurance for genetic testing. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for outpatient diagnostic tests/genetic testing. You have been asked to pay a 20% coinsurance of the allowed amount for genetic testing. The total allowed amount is $760. The total amount you are being asked to pay is $152 ($760 x 20% = $152). Genetic testing falls within the outpatient diagnostic tests/genetic testing benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for genetic testing provided by a participating provider on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on February 10, 2021.
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 99291 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentatino of 30-74 minutes of critical care services spent on the enrollee. 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 critical care services rendered on February 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation
(A0427, A0425) provided on February 20, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you should not be
responsible for this bill because you had a reaction to the COVID-19 vaccination and you were urged to use an
ambulance by the staff at the vaccination clinic. The Plan denied your request. The Plan says this copayment
was applied correctly. The Plan also states that they are reviewing your concerns in another case.

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 $250
copayment for each one-way Medicare-covered ground ambulance transport.

You have been asked to pay a $250 copayment for the ambulance services. This service was considered
medically necessary and the remainder of the cost was covered by the Plan. 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 ambulance transportation (A0427, A0425) provided on February 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visit, the skin lesion- shaving, and the debridement provided on February 26, 2021.

You asked the Plan to waive the cost share for the specialist office visit, the skin lesion-shaving and the debridement. You say that you would like the Plan to reprocess the claim and not apply the deductible. The Plan denied your request. The Plan says the deductible amount of $109.95 was removed for the office visit and the specialist copayment was applied. The Plan also says you have been asked to pay the correct cost-sharing amount for the remaining services.

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 that applies towards physician surgical services and a $35 copayment after the deductible is met for each Medicare-covered podiatry visit. 

The skin lesion-shaving and the debridement you asked the Plan to waive the cost share for falls within the "Podiatry services" benefit category after the deductible is met for each Medicare-covered podiatry visit. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards physician surgical services and a $35 copayment after the deductible is met for each Medicare-covered podiatry visit. The record shows the skin lesion-shaving and the debridement are considered physician surgical services.

This cost sharing is a contractual obligation that had not been met at the time the specialist office visit, the skin lesion-shaving, and the debridement were received on February 26, 2021. Therefore, we decided that the Plan does not have to waive the cost share for the specialist office visit, the skin lesion-shaving, and the debridement provided on February 26, 2021.