Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management (CPT code 99217) and eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient's current medications (G8427) provided to the enrollee on April 28, 2021.  

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the qualifying initial observation care (99218-99220) or subsequent observation care (99224-99226) was not found in the enrollee's claims history.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  

According to the 2021 AMA CPT Manual code definition: 99217 - Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]). Because the enrollee's claims history does not contain a qualifying initial or subsequent observation care service, the discharge service (99217) will remain denied. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for observation care discharge day management (CPT code 99217) and eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient's current medications (G8427) provided to the enrollee on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 5, 2021.  

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  

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 laboratory testing 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 February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture treatment services provided from March 22, 2021, to April 26, 2021.

You asked the Plan to pay for acupuncture treatment. You say that these services were necessary, and you would like to be reimbursed directly for this treatment. The Plan denied your request. The Plan says acupuncture treatment is only covered for treatment of chronic low-back pain. In addition, the provider in this case does not participate in the Medicare program and does not accept payment from Medicare.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.

However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the diagnosis submitted on this claim is R51 (headache). Therefore, we decided that the Plan does not have to pay for the acupuncture treatment services provided from March 22, 2021, to April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete denture - mandibular (D5120).  

You asked the Plan to pre-approve a complete upper and lower denture. You say that you would like the dentures covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for dentures.  

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. The Plan covers a complete upper and lower denture once every five plan years.  

We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper and lower denture were previously covered on April 12, 2019. Based on this information, we decided that the Plan's frequency limit for coverage of a complete upper and lower denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye exam (CPT code 92015) provided to the enrollee on January 13, 2021, by an out-of-network provider.  You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network with the enrollee's health plan.  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 eye exam (CPT code 92015) provided to the enrollee on January 13, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from December 22, 2021, forward.

You asked the Plan to pre-approve continuation of inpatient mental health care. You say that you were monitored for medication and you just had new medication ordered. You state that your mediation was increased on December 20, 2021, and you are not ready to be discharged. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 continuation of inpatient mental health care. Our physician reviewer found based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of December 22, 2021, forward and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. Imitation showed that you were not showing any signs or symptoms of withdrawal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care from December 22, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a bone growth stimulator to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the OON bone growth stimulator. You say that the records provided support the need for a bone growth stimulator. The Plan denied your request. The Plan says no medical need was shown as to why the enrollee cannot get the item from a provider within the network.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator to be provided by an out-of-network (OON) provider.
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 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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided indicating medical necessity for LTACH services. 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 he 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.  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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography (77067) provided on April 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the diagnostic service. You say that you reviewed the Plan's policy for breast imaging and no authorization is required for these services. Please review attached medical records for reconsideration of payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 screening mammography (77067) provided on April 19, 2021 by an out-of-network (OON) provider.
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 SNF services. The Plan denied your request. The Plan says you do not require daily skilled nursing or therapy in a SNF 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 SNF services. Our physician reviewer found that you were at a minimal assist level for donning slip-on shoes, maximal assist for standing, standby assist for walking, and standby assist for washing hands. You do not have documented skilled nursing or skilled therapy needs. You appear to be functioning at or near your baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services (G0493) provided from December 18, 2020, through January 8, 2021.  

You asked the Plan to pay for the skilled nursing services. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says these claims as billed are not covered by Medicare.  

The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  

We looked at the file and Medicare rules. In this case, no records were submitted which support the services billed on the dates of service in question. Without these medical records, we cannot confirm the validity of the billed services. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services (G0493) provided from December 18, 2020, through January 8, 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 enrollee does not meet criteria for IRF admission.  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 enrollee does not meet criteria for IRF admission. 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 lower extremity weakness and had thoracic laminectomy because of spinal metastasis of squamous cell carcinoma. 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, in 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.  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 acute inpatient rehabilitation facility (IRF) admission and services. 

You asked the Plan to pre-approve IRF care. You say that the enrollee needs to get back to baseline function in mobility. The Plan denied your request. The Plan says the enrollee does not require an intensive multidisciplinary approach to daily 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 physician reviewer found that in this case, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care.   

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. She continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement. However, there is no indication that he would require skilled rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status.  

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: 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 your heart rate needs to be checked you are physically active, and you need to rebuild strength and endurance with intensive therapy. The Plan denied your request. The Plan says the stay is not medically necessary.

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 you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to be at/approaching a plateau in function. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care. 

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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services (99253) provided June 29, 2021.  

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is not eligible for payment.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  

We find that CPT code 99253 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, the CPT code billed has a status of "I" and is invalid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99253) provided June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on June 29, 2021.

You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you felt rushed through the appointment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each specialist visit. 

You have been asked to pay a $40 copayment for the specialist telehealth visit. Specialist telehealth visits fall within the Physician/Practitioner Services Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on June 29, 2021.