Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the walking boot provided on July 21, 2021.  You asked the Plan to waive the coinsurance for the walking boot. You say that the physician office advised that the walking book would be covered and should be paid at 100%. You say you only wore the walking boot for a short period of time. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for each in-network Medicare-covered durable medical equipment and related supplies.   You have been asked to pay $67.92 which is 20% of the allowed amount for the walking boot. The allowed amount is $339.59. ($339.59 x 20% = $67.92). The walking boot falls within the "Durable medical equipment (DME) and related 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 the walking boot provided on July 21, 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 admission to an LTACH is medically necessary. 
The Plan denied your request. The Plan says the admission to an 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting 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.   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 angiography services provided on April 26, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says this service is inclusive to the main procedure.  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 75710 is angiography, extremity, unilateral, radiological supervision and interpretation. We looked at the file and the rules. We find that the services described in CPT code 75710 are inclusive to the primary procedure. A service that is an integral part to a more comprehensive procedure should not be unbundled. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the angiography services provided on April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a total knee arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is approved for a total knee arthroplasty. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for exploration of spinal fusion (CPT code 22830-59) and removal of posterior nonsegmental instrumentation (eg, Harrington rod) (CPT code 22850-59) provided to the enrollee on June 2, 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 services are not supported by 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.  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 services. Our reviewer found CPT code 22830-59 - exploration of a spinal fusion on June 2, 2021, does not meet criteria for billing or reimbursement consideration. 
The medical records provided does not validate that an exploration of a spinal fusion was performed as a distinct, separate procedure on June 2, 2021. Therefore, 22830 is inclusive to CPT code 22612, which was performed during the same operative session on June 2, 2021. Although a modifier is allowed to unbundle these services, the medical records provided do not support the use of a modifier, therefore, 22830 is not eligible for separate reimbursement.  CPT code 22850-59 - removal of posterior nonsegmental instrumentation (Harrington rod) provided on June 2, 2021, does not meet criteria for billing or reimbursement consideration. The medical records provided does not validate that a removal of posterior nonsegmental instrumentation (Harrington rod) performed as a distinct, separate procedure on June 2, 2021. 
Therefore, 22850-59 is inclusive to CPT code 22840-59 which was performed during the same operative session on June 2, 2021. Although a modifier is allowed to unbundle these services, the medical records provided do not support the use of a modifier, therefore, 22840-59 is not eligible for separate reimbursement.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for exploration of spinal fusion (CPT code 22830-59) and removal of posterior nonsegmental instrumentation (eg, Harrington rod) (CPT code 22850-59) provided to the enrollee on June 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve removal/vaporization of the basivertebral nerve for the enrollee.  You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.  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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed to show safety and efficacy.  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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve removal/vaporization of the basivertebral nerve for the enrollee.
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 admission to an LTACH is medically necessary. 
The Plan denied your request. The Plan says the admission to an 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where she is currently receiving care. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.  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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Zoomer transportation chair.  You asked the Plan to pre-approve a Zoomer transportation chair. You say that this specific item is similar to what you have had covered in the past. 
The Plan denied your request. The Plan says this device is not intended to be used for a medical purpose and therefore not covered by Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a Zoomer transportation chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from December 23, 2021, forward.  You asked the Plan to pre-approve inpatient psychiatric care from December 23, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 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 inpatient psychiatric care from December 23, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of December 23, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond December 23, 2021, as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from December 23, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 23, 2021, forward.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aduhelm for the enrollee.  You asked the Plan to pre-approve Aduhelm. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the use of Aduhelm in this member is not reasonable and necessary.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aduhelm. Our reviewer says that Aduhelm is not medically reasonable and necessary for the enrollee. Aduhelm is FDA-approved for the treatment of Alzheimer's disease in patients with mild cognitive impairment or mild dementia stage of disease. The clinical documentation does not support a diagnosis of Alzheimer's disease. The use of Aduhelm is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Aduhelm.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm for the enrollee.
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. You say that SNF care is medically necessary. The Plan
denied your request. The Plan says the enrollee does not need daily skilled therapy or daily skilled nursing
services. The Plan says that the enrollee's needs can be met at a lower level of care.
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 reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented
skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is
ambulating more than 100 feet. Daily skilled services are not shown to be required to establish a maintenance
program or to prevent deterioration of the enrollee's condition. The enrollee's 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on August 20, 2021.  You asked the Plan to waive the copayment for emergency care. 
You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $90 copayment for emergency care.   You have been asked to pay a $90 copayment for emergency care. Emergency care 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 emergency care provided on August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673).  You asked the Plan to pay for a pneumatic compression device. You say that the items were medically necessary. The Plan denied your request. The Plan says the pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting.  
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. 
Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for a critical care evaluation and management service (99291)
and bronchoscopy (31624) provided on August 21, 2021.
You asked the Plan to pay for critical care visit and bronchoscopy. You say that you are appealing with
supporting records. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because code 99291 is a duplicate of a charge that the Plan already paid, and code 31624 is a non-
anesthesiology service that is not allowed to be reported by an anesthesiologist.
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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes. The CPT Code Manual definition of code 31624 is
bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar
lavage.
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 critical care visit and bronchoscopy.
Our reviewer says that these codes do not meet the Medicare criteria for payment. Our reviewer found the
record does not include enough documentation to support that service 99291 was a significant, separately
identifiable evaluation and management service by the same physician or other qualified health care
professional on the same day of the procedure or other service. The procedure report does not include enough
information to confirm Medicare criteria for 31624 has been met. Report does not specify who performed the
procedure, and who monitored deep sedation. When performing deep sedation, a provider would be required to
monitor and observe the patient while a procedure is being performed by a different procedure.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of critical care visit and bronchoscopy have not been met. Therefore, we decided
that the Plan does not have to pay for a critical care evaluation and management service (99291) and
bronchoscopy (31624) provided on August 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a duplex scan provided on August 26, 2021.  You asked the Plan to waive the copayment for a duplex scan. You say that you were not aware that the facility would be a conflict and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $150 copayment for diagnostic procedures and tests provided in an outpatient hospital facility.  You received a duplex scan at an outpatient hospital facility on August 26, 2021. Therefore, you are responsible to pay the allowed amount of $44.49, which is less than the $150 copayment.    
You have been asked to pay $44.49 for a duplex scan. A duplex scan 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 copayment for a duplex scan provided on August 26, 2021.