Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on May 24, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that this provider was employed by the hospital and these services were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  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. In addition, there is no evidence that there was a Plan provider who referred the member to this out-of-network provider for care (as the referring provider field is blank on the claim form you submitted.) In fact, the medical records submitted show that the doctor who requested this consult is also an out-of-network provider with the Plan. 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 psychiatric diagnostic evaluation provided on May 24, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrical stimulation therapy services coded 97014 provided on April 27, 2021.  You asked the Plan to pay for the electrical stimulation therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.  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 97014 is application of a modality to 1 or more areas; electrical stimulation (unattended). We find that CPT code 97014 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the electrical stimulation therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation therapy services coded 97014 provided on April 27, 2021.
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 an IRF admission should be covered. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the outpatient cataract surgery you had on June 14, 2021.  You asked the Plan to waive the coinsurance for the cataract surgery. You did not provide an argument with your appeal request. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that because you are also on Medicaid, your state Medicaid agency pays your coinsurance amount.  The Plan has called the provider and advised them to bill your Medicaid plan for this 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 20% coinsurance for outpatient surgery. You have been asked to pay 20% coinsurance for the cataract surgery. the cataract surgery falls within the outpatient surgery 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 the outpatient cataract surgery you had on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical and imaging services rendered on June 18, 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 77002 is not supported and code 20610 was not billed correctly.  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 77002 is fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure).  We find that CPT code 77002 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. Based on this information, we decided that Medicare rules for coverage of these services have not been met.  The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.  The file shows that billed procedure code 20610-RT (arthrocentesis) was billed with a mismatched primary diagnosis code. The code was billed for a right-sided procedure and the diagnosis code is for "unlisted" location, which is not appropriate for this code.  The Plan states that they are not holding you financially responsible for these services and are awaiting a corrected claim from the provider.  Therefore, we decided that the Plan does not have to pay for the surgical and imaging services rendered on June 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for medical services provided on December 10, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON medical services. You say that these services were provided in good faith and were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  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. It is the provider's obligation to confirm the patient's insurance coverage prior to rendering services. 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 medical services provided on December 10, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on May 18, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 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 provided on May 18, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the physical therapy services you had with an out-of-network provider from May 14, 2021, to May 18, 2021.  You asked the Plan to waive the coinsurance for the out-of-network physical therapy services. You say that you called the plan and verified that this provider was in-network. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The Plan says that the phone records state that you called in and inquired about the network status of a different provider, not the provider of these physical therapy services.  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 50% coinsurance for outpatient rehabilitation services with an out-of-network provider.   You have been asked to pay 50% coinsurance for the out-of-network physical therapy services. 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 the physical therapy services you had with an out-of-network provider from May 14, 2021, to May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded as 99153 provided on September 11, 2020.

You asked the Plan to pay for the moderate sedation services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the services are not separately paid according to Medicare rules.

The Plan must follow Medicare rules. Medicare rules say that a PC/TC indicator of 3 represents TC only codes. This indicator identifies stand alone codes that describe the technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the professional component of the diagnostic tests only.

We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a PC/TC indicator of 3 and no separate PC payment. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded as 99153 provided on September 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $800 copayment for inpatient care and the $225 copayment for ambulance transport provided to the enrollee.
You asked the Plan to waive these copayments. You say that these copayments are not correct. The Plan denied your request. The Plan says they received appeals for $800 for inpatient care and $225 for ambulance transport that appear to be confusing. As a courtesy they addressed both types of copayment in the appeal. The Plan says these copayments were charged based on the services provided and the Plan contract agreement.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
The enrollee's contract with the Plan clearly says that enrollees must pay $225 for ambulance transport and $200 per day for days 1 to 5 ($800 total for 5 days) for inpatient care. The enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the $800 copayment for inpatient care and the $225 copayment for ambulance transport provided to the enrollee from May 10, 2021, to May 14. 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that the enrollee is in danger because she lives alone and could fall and severely hurt herself. You say that the enrollee does not have anyone to help her while at home and the doctors feel she needs 24 hours of rehabilitation to help her get better because she has had a stroke. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the services needed can safely be received at a different setting.  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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and clear lungs. The enrollee received physical therapy and occupational therapy. By the dates in question, the enrollee was at a supervision to stand-by assist level with functional mobility including gait to 120 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.  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 was admitted for confusion, falls, and coronavirus (COVID-19) pneumonia.. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 would be the most appropriate care for the enrollee. The Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not meet the requirements for approval.  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 an 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of pembrolizumab (Keytruda).  You asked the Plan to pre-approve pembrolizumab. You say that the enrollee cannot receive intravenous chemotherapy, so you recommend proceeding to immunotherapy with pembrolizumab. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because pembrolizumab cannot be use unless the enrollee has had at least one other cancer treatment first or if they have a clinical test result showing their cancer has a high number of mutations.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 pembrolizumab. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of pembrolizumab. Our physician reviewer found pembrolizumab is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pembrolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve use of pembrolizumab (Keytruda).
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 an IRF admission should be covered. The Plan denied your request. The Plan says under Medicare, the request 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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.