Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five (5) outpatient OT sessions.
You asked the Plan to pre-approve five (5) outpatient OT sessions. The Plan denied your request. The Plan says 5 OT visits does not meet medical necessity criteria under Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L34049).
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve five (5) outpatient OT sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. You and your team have been instructed on discharge planning. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of five (5) outpatient OT sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve five (5) outpatient OT sessions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the polycarbonate lens (V2784), progressive lens (V2781),
frames (V2020), and sales tax (S9999), provided on December 30, 2020.
You asked the Plan to pay for the lens, frames, and tax. You say that the items should be covered. The Plan
denied your request. The Plan says you exceeded the Plan's allowed vision benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The rules state that members are allowed up to one pair of eyeglasses (lenses and frames) every year
with a $200 allowance.
We looked at the file and the Plan's rules. The rules state that members are allowed up to one pair of eyeglasses
(lenses and frames) every year with a $200 allowance. Based on this information, we decided that the Plan's
rules for coverage of lens, frames, and tax have not been met. Specifically, you exceeded the Plan's allowed
benefit of one pair of eyeglasses. This means the second pair of eyeglasses is not covered and you are
responsible for the cost. Therefore, we decided that the Plan does not have to pay for the polycarbonate lens
(V2784), progressive lens (V2781), frames (V2020), and sales tax (S9999), provided on December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied
your request. The Plan says the enrollee does not meet Medicare criteria for admission to an IRF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. Medically necessary services can be provided in a different level
of 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on February 26, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that the facility and doctor are contracted providers. You say the claim should be paid due to patient condition and the pandemic. The Plan denied your request. The Plan says no prior authorization was 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 laboratory work provided on February 26, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endocrinology office visit provided on
October 22, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that you were told there was no
copayment for a virtual visit with a specialist. The Plan denied your request. The Plan says the copayment
amount you are being charged is correct.
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 $30
copayment for specialist visit.
You have been asked to pay $30 copayment for specialist visit. Specialist visits fall within the
Physician/Practitioner Services, Including Doctor's Office Visits 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 an endocrinology office visit provided on October 22, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit (90832) provided on December 31, 2020, by an out of network provider.
You asked the Plan to pay for a psychotherapy visit. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out of network care have not been met.
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 a psychotherapy visit (90832) provided on December 31, 2020, by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nail debridement provided by an out-of-network provider on August 27, 2020.
You asked the Plan to pay for the nail debridement. You say that the medical records should be reviewed, and the claim should be processed for payment. The Plan denied your request. The Plan says utilization of in-network providers is required unless the Plan pre-approves 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 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 nail debridement provided by an out-of-network provider on August 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the heart ultrasound provided on January 7, 2021.
You asked the Plan to waive the copayment for the heart ultrasound. You say that this service was set up by your primary care doctor and it should have been covered by your insurance. The Plan denied your request. The Plan says you have been asked to pay 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 $125 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-network physician's office or at an in-network free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a $125 copayment for the heart ultrasound. The heart ultrasound 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 heart ultrasound provided on January 7, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 13, 2020, through October 21, 2020.

You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan that based on the care, the enrollee did not have to be admitted as an inpatient to the hospital for seven nights. Instead, the care could have been given at an observation level.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was a then, 67-year-old male who presented to the hospital Emergency Department (ED) on October 13, 2020. He presented to the ED with complaints of shortness of breath for 15 days with palpitations. His past medical history included diabetes, hypertension and hyperlipidemia. He was admitted for further work up for acute coronary syndrome and then discharged October 21, 2020. The record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from October 13, 2020, through October 21, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid examination and selection; binaural (92591)
provided January 28, 2021.

You asked the Plan to pay for the hearing aid exam. You say that you do not have hearing aids, did not
purchase hearing aids on this date and you thought hearing exams were covered as part of your benefits. The
Plan denied your request. The Plan says the hearing aid exam is not covered under your benefits when provided
by an OON provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aid exams only when rendered by a network provider.

We looked at the file and the Plan's rules. In this case you were billed for a hearing aid exam. This service was
rendered by an OON provider. Based on this information, we decided that the Plan's rules for coverage of the
hearing aid exam have not been met. Therefore, we decided that the Plan does not have to pay for the hearing
aid examination and selection; binaural (92591) provided January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88360 and 88381)
provided to the enrollee on September 16, 2020, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says this provider is out-of-network, the services were not referred by a network
provider, and the services were not urgent or emergent, nor were they approved in advance.
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 laboratory services (CPT code(s): 88360 and
88381) provided to the enrollee on September 16, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that you had planned Achilles tendon rupture surgery with an in-network provider and after preoperative testing was performed the provider advised they would no longer perform the surgery. The Plan denied your request. The Plan says there are in-network providers that are able to do the procedure that you are requesting.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of the upper or lower extremity arteries (93922) rendered by the out of network (OON) provider on July 31, 2020.
You asked the Plan to pay 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 this service was 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 service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of the upper or lower extremity arteries (93922) rendered by the out of network (OON) provider on July 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra heavy duty manual wheelchair coded as K0007.

You asked the Plan to pre-approve the extra heavy duty manual wheelchair. You say that you need a custom
chair due to your height and weight. Standard wheelchairs are not a correct fit for you. The Plan denied your
request. The Plan says after consultation with a physical therapist, you have been approved for repairs of your
current K0005 wheelchair. With the repairs, this chair will meet your needs.

The Plan follows Medicare rules. Medicare rules say that extra heavy-duty wheelchairs are covered for
enrollees who weigh more than 300 pounds.

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 extra heavy duty manual
wheelchair. Our reviewer says that the documentation does not show that the requested extra heavy-duty
wheelchair is medically reasonable and necessary. Our physician reviewer found the beneficiary is able to
ambulate using a quad cane and also uses a high-strength lightweight wheelchair for mobility. The Health Plan
has authorized a standard wheelchair that can fulfill the mobility needs of the member, or allowed for repairs of
the current chair. The member does not weigh enough to require an extra heavy-duty wheelchair.

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 extra heavy duty manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra heavy duty manual wheelchair coded as K0007.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services (11042) provided on October 10,
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 this claim exceeds Medicare's allowable units
of service for this date of service.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 11042 is 1. You billed 2 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of the debridement services have not been met.
Therefore, we decided that the Plan does not have to pay for the debridement services (11042) provided on
October 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on January 25, 2020, through January 27, 2020.

You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says this was reported with the incorrect DRG.

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, which is based, in part, on the reported principal and secondary diagnosis codes.  

In this case, you billed the inpatient services provided with DRG 193. 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 per the reviewed documentation, she presented to the facility with fatigue, cough, and decreased intake. The provider cites disagreement with the removal of code G93.41 (Metabolic encephalopathy), suggesting the diagnosis was supported based on physician documentation, clinical findings, medical literature, and coding guidelines. The physical exams in the ED note, the history and physical, and the progress note on January 26, 2020, all indicated that the patient was at baseline mental status. There was no significant alteration in mental status beyond the patient's baseline at the time of admission or during the course of the hospitalization, which would justify the coding of encephalopathy. Therefore, the clinical evidence did not support the diagnosis. The review indicates that the appropriate DRG for hospital services 1/25-1/27/2020 was DRG 195. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed.Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on January 25, 2020, through January 27, 2020.