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

We decided that the Plan does not have to pay for the supervision of a nursing facility enrollee coded 99380 provided on March 26, 2021.
You asked the Plan to pay for the supervision of a nursing facility enrollee. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 99380 is supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care
decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more. We find that CPT code 99380 is not supported in the medical record. Specifically, this code has a status indicator of "B". This means that payment for this code is always bundled into payment for other services not specified and no separate payment can be made. Based on this information, we decided that Medicare rules for coverage of the supervision of a nursing facility enrollee have not been met. Therefore, we decided that the Plan does not have to pay for the supervision of a nursing facility enrollee coded 99380 provided on March 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services rendered on May 28, 2021, through June 18, 2021.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that the enrollee had poor care during their previous inpatient admission, and you don't feel he should be responsible for the related costs. The Plan denied your request. The Plan says the copayment has been applied correctly. Your other concerns are being addressed under separate appeals.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $310 copayment for per day for days 1-7 per inpatient hospital admission.
The enrollee has been asked to pay a total of $2,170 ($310 copayment x first 7 days = $2,170) for the inpatient rehabilitation services. This inpatient stay falls within the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. 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 copayment for the inpatient rehabilitation services rendered on May 28, 2021, through June 18, 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 for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided July 31, 2020 to August 2, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says that the services rendered were not medically necessary.
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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was brought to the Emergency Department (ED) on July 31, 2020 for evaluation after a fall. The enrollee had no loss of consciousness. The enrollee was found to have right upper lip laceration status post repair in the ED, a comminuted patella fracture, right maxillary fracture, and a very small subdural hematoma. The enrollee was neurologically intact. The enrollee was admitted to neuroscience unit. Neurosurgery consulted and no further intervention or imaging was recommended. The enrollee was also evaluated by Orthopedic surgery for left patella fracture who recommended a knee immobilizer and weight bearing as tolerated. The enrollee was also recommended to keep her left knee extended. The enrollee's neurology checks remained stable. The enrollee was discharged on August 2, 2020 with instructions to follow up with primary care physician in one week and Orthopedics in two weeks. The review indicates that the record showed that at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided July 31, 2020 to August 2, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99498) provided February 12, 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 documentation does not support the billed services.

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 99498 is Advance Care Planning, Each additional 30 minutes. 

We find that CPT code 99498 is not supported in the medical record. Specifically, the documentation does not detail how much additional time was spent on this service. 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 (99498) provided February 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services (G0299) provided to the enrollee from December 28, 2020 to December 31, 2020.
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed correctly as a home health claim.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was not billed with the correct type of bill and location code. Therefore, we decided that the Plan does not have to pay for the home health services (G0299) provided to the enrollee from December 28, 2020 to December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy provided on May 11, 2021 and the prefabricated post and core provided on May 20, 2021.
You asked the Plan to pay for endodontic therapy and prefabricated post and core. You say that these were necessary dental procedures that were required to save this tooth. You say that you lost your employment income and the expense should be approved. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for endodontic therapy provided on May 11, 2021 and the prefabricated post and core provided on May 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four home health skilled nursing visits. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records from September 4, 2021 to 
September 8, 2021 report you have unstable balance, upper back pain, and shortness of breath with activity. 
There are no more recent records on or around October 13, 2021 documenting an acute or unstable condition 
requiring additional skilled services. The home health services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve four home health skilled nursing visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on November 14, 2020, to November 25, 2020.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you feel that since you were in the hospital for more than 10 days, the cost share should be waived. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $285 copayment per day, for days 1 to 7 and a $0 copayment per day, for days 8 to 90, for inpatient hospital care.

You have been asked to pay a $285 copayment per day for inpatient hospital care. The records show you were inpatient for twelve (12) days. The EOC confirms $285 per day, is the required copayment for this service. Therefore, your total cost share responsibility is $1,995 ($285 x 7 days = $1,995). 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 inpatient hospital care provided on November 14, 2020, to November 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 3, 2021, to May 7, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you do not believe you should be held responsible to pay for an extra hospital stay. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $320 copayment per day, for days 1 to 5 and a $0 copayment per day for additional days, for inpatient hospital care.
You have been asked to pay a $320 copayment per day for inpatient hospital care. The records show you were inpatient for four (4) days; therefore, your total copayment responsibility is $1,280 ($320 x 4 days = $1,280). The EOC confirms $320 per day is the required copayment for this service. 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 inpatient hospital care provided on May 3, 2021, to May 7, 2021.
Your complaint about your recent inpatient hospital care is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 13, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit (99203). You say that you would like the Plan to approve a retro-active prior authorization for the service. The Plan denied your request. The Plan says the services were not urgent or emergent nor approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on May 13, 2021 by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you no longer require daily skilled services in an inpatient SNF setting and the continuation of SNF 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110), initial periapical x-ray (D0220), and additional periapical x-rays (D0230 x 3) provided on May 27, 2021.
You asked the Plan to pay for the dental services. You say that this group has been your physicians for 38 years. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services received out of network are not covered. The Plan also says there is no record that you contacted customer service prior to the date of service to obtain authorization to receive these services out of network.
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 dental services you received are not
among those covered under this benefit when they are provided by an out of network dentist. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), initial periapical x-ray (D0220), and additional periapical x-rays (D0230 x 3) provided on May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says all services that would be provided in the LTACH are being provided in the current acute care setting which is already approved.
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 that in this case the, enrollee was admitted with hypoxic respiratory failure due to coronavirus pneumonia. The enrollee has had a prolonged hospital course complicated by acute kidney injury, encephalopathy, and delirium. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.
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 admission to a long-term acute care hospital (LTACH) for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B medication provided on December 24, 2020.
You asked the Plan to waive the coinsurance for the Part B medication. You say that you have never paid for this before. You say you were not told you would have to pay for the shot. 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 Medicare-covered Part B drug.
You have been asked to pay 20% of the allowed amount for the Part B medication. The allowed amount is $519.84. ($519.84 x 20% = $103.97). The Part B medication falls 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 the Part B medication provided on December 24, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of 
osteoporosis. She has not tried and failed the Plan's required drugs, zoledronic acid and an oral bisphosphonate. 
The records do not show that the required drugs would be contraindicated or less effective; therefore, the Prolia 
is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.