Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department services provided on September 25, 2021.
You asked the Plan to waive the copayment for the emergency department services. You say that you believe this copayment should be waived. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. You have been asked to pay a $90 copayment for the emergency department services. This service falls within the emergency care 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 emergency department services provided on September 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy (D3310) provided on April 15, 2021.
You asked the Plan to pay for endodontic therapy. You say that you were misled into changing your dental
policies. You also say that if you knew you would be stuck with a $1,500 bill, you would have stayed with your
previous dental Plan. You are asking for reconsideration of the denied charges. The Plan denied your request.
The Plan says there is no coverage for endodontic therapy, anterior tooth (excluding final restoration) services.
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
endodontic therapy (D3310) provided on April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 29, 2021, through July 7, 2021.
You asked the Plan to pay for inpatient hospital care. You say that the claim underpaid DRG 246. The Plan denied your request. The Plan says the enrollee's diagnosis was coronary artery disease and their doctor states in the enrollee's medical record that the enrollee was admitted to the hospital for evaluation and treatment of their coronary artery disease. The Plan states the medical records provided for review do not support acute-on-chronic congestive heart failure, no pleural effusion of other signs of pulmonary edema were noted, and no brain natriuretic peptide (BNP) blood testing was done to support the diagnosis of congestive heart failure (CHF). The Plan states the enrollee's doctor does not document CHF in the hospital discharge summary.
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. 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 inpatient hospital care. Our physician reviewer found the review indicates that the enrollee presented for an elective admission on June 29, 2021, due to an abnormal stress test. The enrollee underwent cardiac catheterization with PCI to RCA. The enrollee has a history of previous intervention to another coronary artery. ECHO this admission has the LVEF 53%, mild diastolic dysfunction. The history and physical in these documents, was done in the cardiology office and are noted to be current with no changes. There is no documentation of a CHF exacerbation, and no BNP was done. No effusions are noted on imaging, no JVD reported. The review has determined that DRG 246 was not appropriate by the medical records provided. 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 care provided to the enrollee from June 29, 2021, through July 7, 2021.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 the enrollee appears to be somewhat unstable and should require short-term additional acute care services such as additional weaning attempts that can be safely received at the current hospital for now. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.   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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for paramedic intercept services (S0207) provided on May 16, 2021.  You asked the Plan to pay for paramedic intercept. You say that you do not understand why this service is denied when the other ambulance services were approved and paid. The Plan denied your request. The Plan says you were not transported by this ambulance service, and therefore no payment can be made.  The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York.  The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic intercept services (S0207) provided on May 16, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you do not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management services (99490) provided on August 31, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for chronic care management services. You say that the facility requested this provider to be called in to see the patient as an attending provider in an outpatient capacity. You also say that there is a medical necessity pre-established with the patient and the facility for the provider to provide services to the patients needing care. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and these services are 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 chronic care management services (99490) provided on August 31, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on February 24, 2021.  You asked the Plan to pay for the ambulance response without transport. You say that these services were medically necessary, and you do not see why this bill is not being paid. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. When transportation is not provided, there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on February 24, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on February 24, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the incision of hip tendons (27006) provided on February 17, 2021.
You asked the Plan to pay for the incision of hip tendons (27006). The Plan denied your request. The Plan says
that CPT code 27006 is not supported in the documentation therefore is not payable.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the record indicates that the Plan reviewed medical records to
support the denial. The Plan has not forwarded any clinical information and we are unable to determine if the
Plan was justified in denying the billed services. It is the burden of the Health Plan to substantiate their denial
with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that
the Plan has to pay for the incision of hip tendons (27006) provided on February 17, 2021.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life
support, emergency transport, level 1 (A0427) provided May 25, 2021, and the specialty care transport (A0434)
provided May 26, 2021.
You asked the Plan to waive the copayment for the emergency ambulance services and specialty care transport.
You say that you were told that if you were admitted to the hospital, the ambulance copayments would be
waived. The Plan denied your request. The Plan says the copayments were applied 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 $250
copayment for each one-way Medicare-covered ground trip by ambulance.
You have been asked to pay a total of $500 ($250 copayment x 2 transports = $500) for the emergency
ambulance services and specialty care transport. The emergency ambulance services and specialty care
transport fall within the Ambulance 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 ambulance service, advanced life support, emergency transport, level 1 (A0427) provided May 25,
2021, and the specialty care transport (A0434) provided May 26, 2021.
Your complaint about potentially being provided misinformation 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prednisone.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.  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 pre-approve Prednisone.   Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gamunex-C.
You asked the Plan to pre-approve Gamunex-C. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gamunex-C. Our reviewer says that the services are medically necessary. Our physician reviewer found the documentation does support that the Gamunex-C is medically reasonable and necessary for the enrollee. The documentation does support that the Gamunex-C is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gamunex-C have been met. Therefore, we decided that the Plan has to pre-approve Gamunex-C.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0428, A0429, A0425) provided on April 14, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that these services were necessary because of an injury that occurred while you were at a care facility. You feel the facility should be liable for these charges because your aide was not paying attention when you fell. The Plan denied your request. The Plan says this claim was processed correctly, and your copayments were assessed in accordance with your contract. Your quality-of-care concerns are being addressed in a separate letter, but these services were provided, and the copayments stand as assessed.
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 $200 copayment for each one-way ambulance transportation trip.
You have been asked to pay a $200 copayment for each of the ambulance transportation trips provided on April 14, 2021. 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 ambulance transportation services (A0428, A0429, A0425) provided on April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carpal tunnel release for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is not a diagnosis of carpal tunnel syndrome, constant pain or sensory loss in the median nerve distribution, or failure of non-operative treatment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures for the treatment of carpal tunnel syndrome. Additionally, the provided documentation does not fully support an objective corroboration of carpal tunnel syndrome. There are no electrodiagnostic studies noted to have been performed to corroborate right-sided carpal tunnel syndrome. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve carpal tunnel release for the enrollee
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services (63048, 63047, and 63012) provided on April 19, 2021.  You asked the Plan to pay for codes 63048, 63047, and 63012. You say that the medical records support the billing of codes 63048, 63047-59, and 63012-59 provided on April 19, 2021. The Plan denied your request. The Plan says the medical records do not support the billing of codes 63048, 63047-59, and 63012-59 provided on April 19, 2021.  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 63048 is Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure). The definition of code 63047 is Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar. The definition of code 63012 is Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure).  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 codes 63048, 63047, and 63012. Our reviewer says that the medical records do not support the billing of codes 63048, 63047-59, and 63012-59 provided on April 19, 2021. Our reviewer found the documentation submitted was reviewed, and Medicare billing criteria have not been met. For code 63048, the operative report does not support a different interspace and segment from the arthrodesis performed.  Medicare covers decompression separately when performed at different levels. For code 63047, the operative report does not support a different interspace and segment from the arthrodesis performed. Medicare covers decompression separately when performed at different levels. For code 63012, the operative report does not support code 63012 as a distinct procedure service from code 22633.  Documentation supports a laminectomy was performed to prepare vertebrae for fusion, for posterior interbody technique, and therefore would be included in code 22633.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 63048, 63047, and 63012 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services (63048, 63047, and 63012) provided on April 19, 2021.