Persius/hicric huggingface dataset:
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 cannot walk and have no strength in your legs,
you suffer from acute kidney failure, and hypertension. You state that you need to have IRF care as skilled
nursing facility (SNF) care is not able to provide the level of care needed to make a safe transition home. The
Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan
states your care is routine in nature and can be safely deceived with in a SNF or with home health care.
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 are medically stable. With your comorbid conditions being stable, you do not
need PM&R physician supervision three (3) times per week (at a minimum) for the ongoing management of
any active or acute exacerbations of chronic medical conditions. No acute or complex rehabilitation nursing
needs noted in the record. You do not need intensive therapies, consisting of at least 3 hours of therapy per day
at least five (5) days per week with multidisciplinary approach to daily therapy. For your debility, you do not
require skilled therapists' interventions except routine care. IRF admission is not medically necessary based on
lack of medical complexity, and rehabilitation nursing needs. Document does not support the necessity for
admission to an IRF. While you may benefit from physical therapy (PT), and occupational therapy (OT), your
rehabilitation needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing
facility (SNF).
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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglass frame and lenses provided on September 15, 2021.  You asked the Plan to pay for frame and lenses. You say that you do not agree with the charges and it is difficult for you to pay this bill. The Plan denied your request. The Plan says the coinsurance you are being charged is correct. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you receive a $150 allowance towards the purchase of frames and lenses. The Plan contract also says that you receive an additional 20% off the balance over the $150 allowance.  We looked at the file and the Plan's rules. The records show that you purchased frames and lenses for $350. The Plan applied your $150 allowance which brought your balance to $200 ($350 - $150 = $200). The Plan also applied the 20% discount in the amount of $40. This brings your total balanced owed to $160 ($200 - $40 = $160). Based on this information, we decided that the Plan's rules for coverage of frame and lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frame and lenses provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic services (97012) provided on
June 21, 2021, and July 5, 2021.
You asked the Plan to pay for code 97012. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says code 97012 is not covered when billed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue, code 97012, is not manual manipulation of the spine. Therefore, we
decided that the Plan does not have to pay for the non-covered chiropractic services (97012) provided on June
21, 2021, and July 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
October 30, 2019, to November 8, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the DRG adjustment should be reconsidered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 963. We asked our physician reviewer to
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in
denying the request to pay for the services. Our reviewer says that the services at issue in this case were not
supported by the medical records. Our physician reviewer found the review indicates that DRG 964 is most
appropriate for this case. The review indicates that the documentation supported an admission for displaced
comminuted fracture of shaft of humerus, left arm. The documentation was unclear regarding a diagnosis of
acute tubular necrosis (ATN). Even though ATN is documented in the medical record, supporting
documentation was not found.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided to the enrollee from October 30, 2019, to November 8, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9348 provided February 17, 2021 to February 23, 2021.
You asked the Plan to pay for the home infusion 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 S9348 is home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g., dobutamine); administrative services, professional pharmacy services, care coordination, all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
We find that CPT code S9348 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 home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9348 provided February 17, 2021 to February 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided from May 4, 2021, to May 13, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service did not follow industry standard coding rules.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, the CPT Code Manual definition of code 29530 is strapping; knee. We looked at the file and the rules. A strapping code should not be reported after a therapeutic procedure. Based on this information, we decided that the Medicare rules for coverage have not been met.
The CPT Code Manual definition of code 97035 is Application of a modality to 1 or more areas; ultrasound, each 15 minutes. We looked at the file and the rules. The claim shows that code 97035 was billed with a GY modifier. The claim does not indicate that a therapy modifier was reported. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided from May 4, 2021, to May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic
x-ray (D0330) provided on September 16, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you were
not aware that your insurance plan only covers these services once per year. The Plan denied your request. The
Plan says these services exceed the maximums allowed per period.
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, comprehensive oral evaluation
(D0150) and panoramic x-ray (D0330) are each limited to one procedure every three plan years. The record
shows that you received a comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) on April 23,
2021 and your comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) benefits have been
exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation
(D0150) and panoramic x-ray (D0330) provided on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests (80061, 82306) provided
on September 21, 2021.
You asked the Plan to waive the copayment for the laboratory tests. You say that the cost-sharing should be
covered as they were INR tests. The Plan denied your request. The Plan says the cost-sharing applied correctly
based on the services provided.
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 and therapeutic services and supplies.
You have been asked to pay a $10 copayment for the laboratory tests. The record indicates that the tests
rendered are not considered INR testing and that is why a copayment was assessed. Laboratory tests fall within
the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for laboratory tests (80061, 82306) provided on September 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a meperidine and midazolam injection provided on November 11, 2020.
You asked the Plan to waive the copayment for the meperidine and midazolam injection. You say that the cost-sharing should be covered. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.
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 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for the meperidine and midazolam injections (allowed is $405.65 x 205 = $81.13). Meperidine and midazolam injections fall within the Medicare Part B prescription drugs 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 a meperidine and midazolam injection provided on November 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) coded 70544
provided on September 2, 2021.
You asked the Plan to pay for the MRA. 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 separately 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, we have confirmed that code 70544
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) coded 70544
provided on September 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a midazolam and meperidine injection provided on October 14, 2020.
You asked the Plan to waive the coinsurance for the midazolam and meperidine injections. You say that the services should be covered. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.
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 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for the midazolam and meperidine injections (total allowed is $634.90 x 20% = $126.98). Midazolam and Meperidine injections fall within the Medicare Part B prescription drugs 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 a midazolam and meperidine injection provided on October 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
March 18, 2021, to March 25, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the provider has reported inpatient hospital services with the incorrect DRG.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found the
review indicates that the documentation received supported an admission for further evaluation and treatment
of a catheter associated urinary tract infection in a patient with a past medical history to include multiple
sclerosis, urinary retention requiring self-catheterization, diabetes mellitus, anxiety, and hypertension. The
review has determined that the record did not support that the correct DRG and diagnosis codes were used in
this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided to the enrollee from March 18, 2021, to March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation admission and services provided April 3, 2021, to April 28, 2021.
You asked the Plan to waive the copayment for the inpatient rehabilitation admission and services. You say that you were told there would be no cost for the services because it was related to coronavirus. The Plan denied your request. The Plan says there is an approved authorization on file for a 1-day rehabilitation stay and the copayment was applied correctly. The Plan also says that they could not find evidence that you were told by the Plan that a cost share would not apply.
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 $295 copayment per day, days 1 to 6 for each Medicare-covered hospital stay.
You have been asked to pay a $295 copayment for the inpatient rehabilitation admission and services. The inpatient rehabilitation admission and services fall within the Inpatient hospital 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 inpatient rehabilitation admission and services provided April 3, 2021, to April 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states the
services you require, such as additional therapy services, can safely be received at a different setting, for
example, home with home health, in residential care, or home with close follow-up with your doctor.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that the enrollee needs to be back to 100% before going home. You state the enrollee lives alone, has congestive heart failure, chronic obstructive pulmonary disease (COPD), and is on oxygen. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states the services you require, such as additional therapy services, can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with the enrollee's doctor.  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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 25, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy (77295, 77334, 77300)
provided on August 19, 2021.
You asked the Plan to waive the coinsurance for the radiation therapy. You say that the services should be
covered as you informed the office you could not afford to pay and the provider stated they would waive the
costs. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services
provided
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 20%
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a 20% coinsurance for radiation therapy (the total allowed is $690.83 x 20% =
$138.166). Radiation therapy falls within the Outpatient diagnostic tests and therapeutic services and supplies
benefit category. This means that you have been asked to pay the correct amount based on your contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the coinsurance for radiation therapy (77295,
77334, 77300) provided on August 19, 2021.