Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 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 based on the documentation provided you only require short-term additional acute care services that can safely be administered at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility.  

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 an expandable control system. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee is able to control the power options using their own switches.  The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications.   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 requested services. Our physician reviewer found that you had a recent stroke with left side hemiparesis. You have been mostly bed bound since. You are receiving physical therapy and need assist with mobility, transfers, and activities of daily living. You have good right hand grip with full range of motion. You were approved for a power wheelchair with tilt, recline, and elevating leg rests. The records do not show that you need to control the power options through a joystick. Your upper extremity strength and function with independence in eating support that you can control any power options through their own switches.  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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable control system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for inpatient hospital care provided from August 23, 2021, to August 25, 2021.

You asked the Plan to waive the deductible for inpatient hospital care. You say that the inpatient hospital care you received was out of your control 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. Your contract with the Plan says that there is a $750 deductible which applies to inpatient hospital care. You received inpatient hospital care from August 23, 2021, to August 25, 2021. The record shows that you had only paid $292.47 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $457.53. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time inpatient hospital care was received on August 23, 2021 to August 25, 2021. Therefore, we decided that the Plan does not have to waive the deductible for inpatient hospital care provided from August 23, 2021, to August 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the basic support routine supplies (A0382), intravenous drug therapy supplies (A0394), routine disposable supplies (A0398), and ambulance oxygen and oxygen supplies (A0422) provided on November 27, 2020. 

 You asked the Plan to pay for the basic support routine supplies, intravenous drug therapy supplies, routine disposable supplies, and ambulance oxygen and oxygen supplies. You say that you feel that you should not be held responsible for payment of these services. The Plan denied your request. The Plan says the Medicare rules for coverage have not been met as the services are not covered by Original Medicare.  

The Plan must follow Medicare rules. Medicare rules say that items and services which include but are not limited to oxygen, drugs, extra attendants, supplies, electrocardiogram (EKG), and night differential are no longer paid separately for ambulance services.  

 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the basic support routine supplies, intravenous drug therapy supplies, routine disposable supplies, and ambulance oxygen and oxygen supplies have not been met. Therefore, we decided that the Plan does not have to pay for the basic support routine supplies (A0382), intravenous drug therapy supplies (A0394), routine disposable supplies (A0398), and ambulance oxygen and oxygen supplies (A0422) provided on November 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a scapular nerve block for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records do not show any of the approvable indications.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that this type of injection has not been proven for safety and effectiveness. Approvable indications for suprascapular nerve blocks are in the treatment of malignant pain, treatment of headaches, or treatment of the pain after a hernia repair.  The review has determined that the services at issue in this case are not medically reasonable and 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a scapular nerve block for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 1, 2022, forward.  

You asked the Plan to pre-approve inpatient psychiatric care from January 1, 2022, 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 January 1, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of January 1, 2022, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond January 1, 2022, 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 January 1, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 1, 2022, forward.
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 requested admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided June 22, 2021.
You asked the Plan to pay for therapeutic activities. You say that many of the requested services in 2020 are not available on an outpatient basis secondary to the recent Covid-19 pandemic. Please review all attached documentation supporting this request and process your claim for payment. The Plan denied your request. The Plan says the code is not appropriate for 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 97530 is therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, the records indicate that the service is performed by an occupational therapist in a home health or hospice setting. There is an appropriate HCPCS code (G0152) for the billed service. Based on this information, we decided that Medicare rules for coverage of therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided June 22, 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 requested admission to an IRF is not medically necessary.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound of the abdomen (76705) provided on August 3, 2021.  You asked the Plan to pay for the ultrasound of the abdomen. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was not billed as required by Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound of the abdomen (76705) provided on August 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from March 11, 2020, to March 16, 2020.  

You asked the Plan to waive the copayment for the inpatient stay. You say that this cost is a financial hardship. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. You are responsible for a $1,750 copayment for a five-day inpatient stay. The provider has offered an additional discount and is charging you $1,400 total including the portion you already paid.  

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 $350 copayment for each of the first five days of an inpatient stay.   

You have been asked to pay a $1,400 copayment for the inpatient stay. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from March 11, 2020, to March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on February 13, 2020. 

 You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

  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 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on  February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on August 18, 2021.
You asked the Plan to waive the copayment for urgently needed services. You say that you were not informed of the copayment at the time services were received and the physician's assistant did nothing to treat your condition. 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 $40 copayment for urgently needed services. You have been asked to pay a $40 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services provided on August 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Percutaneous implantation of Neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555).  

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that these services don't meet criteria for coverage.  

The Plan must follow Medicare rules. Medicare rules say that peripheral nerve stimulators are covered if Medicare criteria for coverage have been met.  

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 requested services are not considered medically reasonable and necessary in this case. This enrollee has chronic bilateral low back pain. The enrollee does not have a specific neuropathy. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for coverage.  

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 Percutaneous implantation of Neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from December 3, 2021, forward.  

You asked the Plan to pre-approve inpatient psychiatric care from December 3, 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 3, 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 3, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond December 3, 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 3, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 3, 2021, forward.