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

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says a LTACH admission is not medically necessary.
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 the short-term acute care hospital can provide for all of the enrollee's present inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. The short-term acute care hospital can provide for all of the enrollee's present inpatient care needs and the health Plan has stated that continued care in the short-term acute care hospital will be covered. The enrollee is presently receiving these services in the short-term acute care setting. Continued care in the short-term acute care hospital is appropriate (and endorsed by the health Plan) until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility.
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 LTACH services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) you had at an outpatient hospital facility on July 30, 2021.
You asked the Plan to waive the copayment for the EGD. You say that the bill doesn't say what the $150 charge is for. You said that you were not told you would have to pay anything for this service. You said that your agent told you had if you had this procedure in an ambulatory surgery center, you would have paid $0. You said you were not informed of this option by the hospital, so you think this copayment should be waived. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $150 copayment for outpatient surgery at an outpatient hospital facility.
You have been asked to pay a $150 copayment for the EGD. The EGD falls within the outpatient surgery at an outpatient hospital facility benefit category. Your contract clearly discloses to you that you pay a $150 copayment if you have surgery at an outpatient hospital facility and $0 if you have surgery at an ambulatory surgery center. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) you had at an outpatient hospital facility on July 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan of the extremity veins you received on June 18, 2021.
You asked the Plan to waive the copayment for the duplex scan. You say that it is not fair you are being asked to pay this amount when insurance pays much less. You said that this should be covered 100% or insurance should pay more towards it. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $155 copayment for radiological diagnostic services. You have been asked to pay a $155 copayment for the duplex scan. The duplex scan falls within the
radiological diagnostic services 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 duplex scan of the extremity veins you received on June 18, 2021
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a comprehensive electrophysiologic evaluation and catheter ablation.
You asked the Plan to pre-approve a comprehensive electrophysiologic evaluation and catheter ablation. You say that a comprehensive electrophysiologic evaluation and catheter ablation is medically necessary. The Plan denied your request. The Plan says that a comprehensive electrophysiologic evaluation and catheter ablation is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that (EES), also called programmed electrical stimulation of the heart, is covered under Medicare when used for patients with severe cardiac arrhythmias 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 comprehensive electrophysiologic evaluation and catheter ablation. Our reviewer says that a comprehensive electrophysiologic evaluation and catheter ablation is medically necessary. Our physician reviewer found that recent randomized clinical studies have supported the role of catheter ablation for the treatment of symptomatic atrial fibrillation and atrial flutter as an acceptable first-line alternative to medications in the treatment of patients with these arrhythmias. Clinical guidelines have been modified to reflect the findings of these new studies. Therefore, electrophysiologic evaluation and catheter ablation would be considered medically appropriate and necessary in this enrollee's clinical management. 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 comprehensive electrophysiologic evaluation and catheter ablation have been
met. Therefore, we decided that the Plan has to pre-approve a comprehensive electrophysiologic evaluation and catheter ablation.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (CPT code 80307 and G0480) provided to the enrollee on November 5, 2020.
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 the appeal records received are improperly amended as the dates are changed with no appropriate documentation to support the change. The Plan states the determination on the claim is based on the original received records. The Plan states the services are not allowable because incorrect billing was identified. The Plan states the date of service on the claim does not align with the records.
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 80307 is drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service and G0480 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. 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 laboratory services. Our reviewer found the record indicates that the enrollee underwent laboratory testing. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code 80307 and G0480) provided to the enrollee on
November 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had on July 27, 2021.
You asked the Plan to waive the copayment for the EKG. You say that this was part of your Welcome to Medicare exam. You said that you never asked for the EKG, so you should not have to pay for it. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $10 copayment for diagnostic tests.
Your contract says that the Welcome to Medicare preventive visit is a one-time visit that includes a review of
your health, as well as education and counseling about the preventive services you need (including certain
screenings and shots), and referrals for other care if needed. It does not include diagnostic testing. You have
been asked to pay a $10 copayment for the EKG. The EKG falls within the diagnostic tests 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 electrocardiogram (EKG) you had on July 27, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on July 23, 2021, to July 24, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you were admitted to the hospital, so you should not have a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $50 copayment for emergency room services.
You have been asked to pay a $50 copayment for the ER visit. 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 room (ER) visit you had on July 23, 2021, to July 24, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an in-home podiatry visit with trimming and debridement of nails provided on July 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON podiatry visit. You say that this was medically necessary and should be paid. The Plan denied your request. The Plan says non-emergency services from OON provider must be authorized by the Plan to be covered. No authorization was requested for this service.
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 an in-home podiatry visit with trimming and debridement of nails provided on July 6, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on May 21, 2021.
You asked the Plan to pay for vision services. The Plan denied your request. The Plan says the claim processed
correctly. The services for visual field exam and Fundus Photography are not covered by the member's plan
and you are responsible for this amount. Also, as per page 79, routine eye exam are covered and eye med has
allowed $40.00. For Frames and lens package out of $199 of total charge, $139.20 has been allowed and they
owe $79.20 as their responsibility.
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.
We looked at the file and the Plan's rules. The file shows that the claim processed correctly. Therefore, we
decided that the Plan does not have to pay for vision services provided on May 21, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from April 12, 2021, through April 20, 2021, billed with principal diagnosis code N13.9.
You asked the Plan to pay for the inpatient services as billed. You say that it is felt this was billed correctly with a valid principal diagnosis. The Plan denied your request. The Plan says the principal diagnosis is not supported which changes the DRG payment.
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 principal diagnosis code N13.9, defined as Obstructive and reflux uropathy, unspecified. 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 inpatient services as billed. Our reviewer says that the reported principal diagnosis code is not supported by the records. Our physician reviewer found official guidelines for coding and reporting require coding to the highest degree of specificity. The documentation states "Discharge Diagnosis: Enterococcus faecalis bacteremia to urinary tract infection (UTI) and instrumentation Bladder cancer with suspected (enlarged prostate causing obstruction". Therefore, the appropriate code to report for this condition is N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms. 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 the inpatient hospital services provided from April 12, 2021, through April 20, 2021, billed with principal diagnosis code N13.9.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) had you had on July 2, 2021.
You asked the Plan to waive the copayment for the EKG. You say that your doctor ordered this EKG as part of your annual physical. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $10 copayment for outpatient diagnostic tests. An annual physical exam includes a bodily systems examination, measurement and recording of vital signs, a
complete prescription medication review, and a review of any recent hospitalizations. It does not include any diagnostic testing, so separate cost sharing can apply. You have been asked to pay a $10 copayment for the EKG. The EKG falls within the outpatient diagnostic tests 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 electrocardiogram (EKG) had you had on July 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve revision gastroplasty surgery (43848).
You asked the Plan to pre-approve revision gastroplasty surgery. You say that revision gastroplasty is medically necessary. The Plan denied your request. The Plan says revision gastroplasty is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that repeat bariatric surgery is generally not reasonable and necessary. Medicare does not provide prior authorization for these services. Claims for more than one bariatric surgical procedure most likely will create a denial. 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 revision gastroplasty surgery. Our reviewer says that revision gastroplasty surgery is not medically necessary. Our physician reviewer found that the available records do not demonstrate the medical necessity of gastric bypass revision for the following reasons: You have nearly doubled your weight over two years with oral (PO) tolerance of medications, supplements, and multiple textures of solid and liquids foods. There is no endoscopic nor radiographic evidence presented of gastric outlet obstruction. There is no objective documentation of malnutrition nor of gastroparesis. The available records do not specify Percocet frequency of use, nor how your use of maximum-
dose Percocet pills may contribute to your gastrointestinal symptoms. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of revision gastroplasty surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve revision gastroplasty surgery (43848).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have three pins in your foot and cannot walk without orthotcs. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 you get confused occasionally and have psychiatric
problems. You say that you are a fall risk at home and cannot bathe/shower by yourself. You say that you are
not ready to go home yet. The Plan denied your request. The Plan says the guidelines for coverage 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 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 pneumonia and hepatic encephalopathy. The enrollee's 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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.