Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital care (99232) provided on December 31, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the documentation submitted does not support the service billed.
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 99232 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. We asked our coder 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 subsequent hospital care. Our reviewer says that CPT code 99232 meets criteria for billing and reimbursement consideration. Our reviewer found documentation must meet or exceed 2 of the 3 key components. History of present illness documents 1 condition, therefore a problem focused exam is supported. 9 organ systems were documented, which supports a comprehensive exam. Medical decision making supports moderate level, because IV fluids and laboratory results reviewed. Therefore, the documentation support level 99232. 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 subsequent hospital care have been met. Therefore, we decided that the Plan has to pay for subsequent hospital care (99232) provided on December 31, 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: 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 transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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
you were admitted with acute hypoxic respiratory failure from COVID-19 pneumonia. The record indicates
that you have a chest tube in pace for a pneumothorax. You are receiving acute care services, and these have
not been denied. The medical record does not indicate that you require services that are not currently being
provided that would be available at the LTACH facility. Medicare criteria are not met for transfer.
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 pay for out of network physician services provided on February 15, 2021.
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 out of network physician services provided on February 15, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ventilator.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode that could be delivered with BiPAP is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has chronic respiratory failure from interstitial lung disease. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The record does not indicate why the enrollee could not be treated with a BiPAP machine with AVAPS capability. The plan has indicated such a device is covered. The elements of the coverage criteria are not satisfied. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the Vertiflex Superion for the enrollee.
You asked the Plan to provide coverage for this surgery. You say that this treatment is medically necessary to
treat back pain. The Plan denied your request. The Plan says medical necessity has not been established.
The Plan must follow Medicare rules. The rules say that services and devices provided must be medically
reasonable and necessary. We asked our physician reviewer to look at the case file and the Medicare rules. Our
physician reviewer says that in this case, the enrollee has chronic low back pain and lumbar spinal stenosis with
neurogenic claudication. The record indicates that imaging has demonstrated mild to moderate severe spinal
stenosis at L2-L3, the level requested for treatment. The record does not indicate that the enrollee is not
indicated for operative intervention at more than two levels because there is a question of stability at his
previous anteriorly fused L3-S1 levels. Based on the medical records provided, the requested service cannot be
recommended.
We looked at this physician review and the Medicare rules. Based on this information, medical necessity
criteria have not been established in this case. Therefore, the Plan is not required to provide coverage for the
Vertiflex device
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided January 5, 2021.
You asked the Plan to pay for the limited oral exam. You say that you previously had similar services covered in past years and would like this covered as well. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 limited oral evaluation - problem focused (D0140) provided January 5, 2021.
Your complaint about receiving coverage for similar services in past years 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the Vertiflex Superion for the enrollee.
You asked the Plan to provide coverage for this surgery. You say that this treatment is medically necessary to
treat back pain. The Plan denied your request. The Plan says medical necessity has not been established.
The Plan must follow Medicare rules. The rules say that services and devices provided must be medically
reasonable and necessary. We asked our physician reviewer to look at the case file and the Medicare rules. Our
physician reviewer says in this case, the enrollee has chronic low back pain and lumbar spinal stenosis with
neurogenic claudication. The record indicates that the enrollee has a body mass index of 46. The elements of
the coverage criteria are not satisfied. The requested service cannot be recommended.
We looked at this physician review and the Medicare rules. Based on this information, medical necessity
criteria have not been established in this case. Therefore, the Plan is not required to provide coverage for the
Vertiflex device for the enrollee.
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 had a fall and need aggressive therapy as you are not able to eat on your own. The Plan denied your request. The Plan says you do not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage.

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 is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require 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 your diagnosis and condition.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interspinous device placement surgery.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that this treatment is considered safe and effective. The Plan denied your request. The Plan says there are not enough studies on the device to show it is safe and effective.

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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous spacer devices remain experimental. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve interspinous device placement surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 a home ventilator. Our reviewer says that the documentation does not support that the requested a home ventilator is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), oxygen dependent, and also obstructive sleep apnea (OSA). The medical records do not include evidence of Carbon dioxide retention on an arterial blood gas.

There is no evidence bilevel positive airway pressure has been tried and failed. Finally, compliance data indicate the enrollee is not using the device sufficiently for it to be effective. Therefore, the enrollee does not meet criteria for the requested device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist services provided on January 15, 2020, and October 7, 2020.

You asked the Plan to waive the copayments for specialist services. You say that you feel that the charges are in error and you should not be responsible for them. 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 $40 copayment for specialist services. 

The medical records show that you received specialist services on January 15, 2020. Therefore, you are responsible to pay the $40 copayment.

The medical records show that you received specialist services on October 7, 2020. Therefore, you are responsible to pay the $40 copayment. 

The total amount you owe is: $80. 

You have been asked to pay the total copayment amount of $80 for specialist services. Specialist services 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 copayments for specialist services provided on January 15, 2020, and October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on June 29, 2021.

You asked the Plan to pay for these services. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you 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 out of network physician services provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99153) provided on December 20, 2020.

You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that services with status indicator N are paid under the Outpatient Prospective Payment System (OPPS), but their payment is packaged into payment for a separately paid service.

We looked at the file and Medicare rules. The code at issue has a status indicator of N and is not separately payable. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99153) provided on December 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nebulizer provided on February 25, 2021.

You asked the Plan to pay for nebulizer, with compressor (E0570). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there was no face to face examination with the referring physician listed on the claim.

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 relevant medical records which support medical necessity for the supplies provided in this case. The physician order is dated a year ago and there is no recent face-to-face to support medical necessity. The recent medical record only mentions a medication refill. 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 nebulizer provided on February 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on February 5, 2021, by an
OON provider.

You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the
member was referred for these services by their primary care physician. The Plan denied your request. The Plan
says these services were not urgent, emergent, or 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 outpatient services provided on February 5,
2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 26, 2021.

You asked the Plan to pay for these services. 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 out of network physician services provided to the enrollee on April 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from February 22, 2021, through February 25, 2021.

You asked the Plan to pay for the self-administered drugs. You say that the medications should be processed under Part D coverage as they were while in rehab private pay. The Plan denied your request. The Plan says Part B doesn't cover self-administered drugs.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from February 22, 2021, through February 25, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.