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

We decided the Plan does not have to waive the $65 copayment for an urgent care visit on June 3, 2021.
You asked the Plan to waive this copayment. You say that the enrollee went to urgent care after a fall. After the urgent care evaluation, the enrollee was advised to go to the emergency room for further treatment. You say that the enrollee believes the urgent care copayment should be waived. The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by the provider and the enrollees Plan contract agreement.
The rules say a plan must disclose to its enrollees all cost sharing information. The contract with the Plan clearly says that enrollees must pay a $65 copayment for urgent care visits. The records show the enrollee was evaluated in urgent care, and based on that evaluation, was advised to go to the emergency room for advanced imaging and a higher level of treatment. This evaluation warrants a copayment. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the $65 copayment charged to the enrollee for an urgent care visit on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of replaceable part of semi-precision or precision attachment (D5867) provided on April 30, 2021.

You asked the Plan to pay for the dental service. You say that you feel the structures that the dentist attached to your natural teeth should be covered. The Plan denied your request. The Plan says replacement of replaceable part of semi-precision or precision attachment is not listed as a covered service.

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 replacement of replaceable part of semi-precision or precision attachment is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the replacement of replaceable part of semi-precision or precision attachment (D5867) provided on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection of lower or sacral spine facet joint using imaging guidance coded as 64494 provided on May 21, 2021.
You asked the Plan to pay for the injection of lower or sacral spine facet joint using imaging guidance. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the claim has denied correctly.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injection of lower or sacral spine facet joint using imaging guidance have not been met. Therefore, we decided that the Plan does not have to pay for the injection of lower or sacral spine facet joint using imaging guidance coded as 64494 provided on May 21, 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 these services are medically necessary. The Plan denied your request. The Plan says that you do not have complex medical management needs, and do not require supervision by a rehabilitation physician.

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.

You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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 inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the care to get hemodialysis would not be expected to cross more than one midnight.
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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the known non-compliance with medical therapy including dialysis treatments. He presented to the emergency department on October 13, 2021 requiring dialysis. He was evaluated and admitted. He underwent dialysis and was discharged home October 15, 2021. The review indicates that he did not require any inpatient diagnostic studies or therapeutic interventions. The review indicates that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.enrollee. The enrollee has a history of diabetes mellitus, hypertension, and end stage renal disease on hemodialysis. He has
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist telehealth visit you had on
June 17, 2021.

You asked the Plan to waive the copayment. You say that you did not see the provider. The Plan denied your
request. The Plan says you are responsible for the copayment.

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 $25
copayment for each Medicare-covered specialist visit.

Review of the file shows that you had a specialist telehealth visit on June 17, 2021. You have been asked to pay
a $25 copayment for the visit. The visit falls within the specialist 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 specialist telehealth visit you had on June
17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedure, 1 or more areas, each 15 minutes (97110) provided November 7, 2019

You asked the Plan to pay for the therapeutic services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the code is not appropriate for the service billed.

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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 

We find that CPT code 97110 is not supported in the medical record. Specifically, the records indicate that the service is performed by a physical therapist assistant in a home health or hospice setting. There is a more appropriate healthcare common procedure coding system (HCPCS) code (G0157) for the service billed. The plan made multiple attempts to obtain additional inform from the provider without success. Based on this information, we decided that Medicare rules for coverage of the therapeutic services have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic procedure, 1 or more areas, each 15 minutes (97110) provided November 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept intraosseous nerve ablation system.
You asked the Plan to pre-approve an intracept intraosseous nerve ablation system. You say that you are in
extreme pain and the requested procedure is needed for relief. The Plan denied your request. The Plan says the
requested procedure is not considered the standard of care.
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 an intracept intraosseous nerve ablation
system. Our reviewer says that an intracept intraosseous nerve ablation system is not considered medically
reasonable and necessary in this case. Our physician reviewer found the intracept 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 an intracept intraosseous nerve ablation system have not been met. Therefore,
we decided that the Plan does not have to pre-approve an intracept intraosseous nerve ablation system.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from April 25, 2021, to
May 24, 2021.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee
had no skilled therapy or skilled nursing service needs and did not meet the guidelines for Medicare coverage.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a skilled nursing facility (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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from April 25, 2021, to May 24, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on March 24, 2021.

You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary
and should be paid. The Plan denied your request. The Plan says there was no consultation with the primary
care or attending physician.

The Plan must follow Medicare rules. Medicare rules say that payment for CP services requires that the CP documents a consultation or attempt at consultation with the enrollee's primary care or treating physician. This must be documented in the record. 

The record does not include any documentation of a consultation or attempted consultation with the attending physician. Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on March 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional physical therapy visits.
You asked the Plan to pre-approve 4 additional physical therapy visits. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 4 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has had prior therapy and has been approved ample therapy to be properly instructed in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.

You asked the Plan to pay for the LTACH services. You say that an LTACH is the appropriate level of care for this enrollee, and they are stable for transfer at this time. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. At the time of this request, the enrollee's status is critical and unstable. The enrollee is receiving medically necessary acute/critical care in the current setting. There are no issues for which an LTACH may offer a therapeutic advantage. The Plan will continue to cover medically necessary care at the current facility until the enrollee is stable for transfer to a lower level of care or until the clinical circumstances change such that an LTACH may be reconsidered.

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 pay for 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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from and improve with LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 

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 pay for long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nephrology visit you had on June 24,
2021.
You asked the Plan to waive the copayment for the nephrology visit. You say that you went in for your annual
wellness check, so there should not be a copayment. The Plan denied your request. The Plan says you were
charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for visits with a specialist.
You have been asked to pay a $40 copayment for the nephrology visit. The nephrology visit falls within the
visits with a specialist benefit category. The medical records from this date of service show that this was not an
annual wellness check. The records show that this was a follow-up visit to go over your conditions of
hypertension and crossed renal ectopia. 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 nephrology visit you had on June 24, 202
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the infusion services provided on March 5, 2021.

You asked the Plan to waive the cost share for chemotherapy administration (96413) and Medicare Part B drug (J1745). You say that you have other insurance so you should not have to pay coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 $100 copayment for administration and 20% coinsurance for Medicare Part B drugs. 

You have been asked to pay a $100 copayment for chemotherapy administration (96413) and 20% coinsurance for Medicare Part B drug (J1745). 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 cost share for the infusion services provided on March 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the x-ray exam of the chest (71046), the catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed (93460), the computed tomographic angiography, of the abdomen and pelvis, with contrast material(s), including non-contrast images (74174), the computed tomography of the heart with contrast (75572), and the computed tomographic angiography of the chest (71275) provided on May 26, 2021 and June 8, 2021. You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 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 $30 copayment for each Medicare-covered x-ray. You must pay a $150 copayment for each Medicare-covered advanced radiology diagnostic service. Both copayments will apply for a diagnostic x-ray and an advanced radiology service if both are billed on the same day by the provider. Additionally, you must pay a $350 copayment for same-day outpatient surgery in an outpatient hospital facility. You have been asked to pay $530 which includes a $30 copayment for the Medicare-covered x-ray, a $150 copayment for the advanced radiology diagnostic service, and a $350 copayment for the outpatient surgery provided in an outpatient hospital facility. 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 copayments for the x-ray exam of the chest (71046), the catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed (93460), the computed tomographic angiography, of the abdomen and pelvis, with contrast material(s), including non-contrast images (74174), the computed tomography of the heart with contrast (75572), and the computed tomographic angiography of the chest (71275) provided on May 26, 2021 and June 8, 2021.