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

 We decided that the Plan does not have to waive the copayment for the pneumatic compressor (E0652), and segmental pneumatic appliance (E0668), provided on February 11, 2021.  You asked the Plan to waive the copayment for the pneumatic compressor and segmental pneumatic appliance. You say that the items should be covered. The Plan denied your request. The Plan says the cost share was applied 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 20% coinsurance for each for durable medical equipment (DME) and related supplies.   You have been asked to pay a 20% coinsurance for each for the pneumatic compressor and segmental pneumatic appliance. This service 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 copayment for the pneumatic compressor (E0652), and segmental pneumatic appliance (E0668), provided on February 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 you do not need intensive therapies, consisting of at least three (3) hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. You will not make a significant progress in the predicted period of time as expected per Medicare guidelines. IRF admission is not medically necessary based on lack of medical complexity and nursing needs. Your rehabilitation needs can be accomplished with therapies in an alternate setting. Document does not support the necessity for admission to IRF. While you may benefit from continued physical therapy (PT), and occupational therapy (OT), your rehabilitation needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility (SNF).  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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99213) and laboratory services (36416, 85610) provided on August 23, 2021.  You asked the Plan to pay for an office visit and laboratory services. You say that you went to an emergency room out of state and are now being billed. The Plan denied your request The Plan denied your request. The Plan says you must see an in network provider. The Plan also says that in most cases, care you receive from an out-of-network provider (a provider who is not part of the plan's network) will not be covered. The Plan also says that if you need medical care that Medicare requires the plan to cover and the providers in the network cannot provide this care, you can get this care from an out-of-network provider. The Plan says that you, or your PCP, must obtain authorization from the plan prior to seeking care and that in this situation, you will pay the same as you would pay if you got the care from a network provider.  Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.    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 an office visit and laboratory services. Our reviewer says that the record provided is insufficient of the urgency of this visit and that the elements of the coverage rules are not satisfied. Our physician also said that therefore, the requested service cannot be recommended. Our physician reviewer found that in this case, the record indicates that the enrollee went to a provider for a lab test to monitor her anti-coagulation status. The record indicates that the enrollee is otherwise stable. The need for the blood work is foreseeable, and it is not reasonable to delay this test for an extended period of time; but the need to have it performed when it was done cannot be ascertained from the records provided.  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 office visit and laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99213) and laboratory services (36416, 85610) provided on August 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter (K0733, K0800).  You asked the Plan to pre-approve the scooter. You say that this is medically necessary, as you have limited mobility and need to be able to get around inside the home independently. The 11/10/21 physician progress note indicates you are independent in eating, bathing, dressing, toileting, and transferring. The physician note encouraged exercise and did not feel that you were a fall risk. There is no detailed home assessment with objective measurements of the maneuvering spaces within the home. You may have the cognition and vision to use the scooter, but the documentation does not support that the scooter will significantly improve participation in MRADLs in the home. Additionally, the physician did not sign the order for the requested K0800 and K0733. The Plan denied your request. The Plan says the records do not have a detailed/signed physician order, home evaluation, treatment notes to include current functional status, and clinical indications for the requested durable medical equipment.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation does not consistently reveal that you have a mobility deficit that impairs MRADLs in the home.  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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0733, K0800).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of SNF care from December 29, 2021, forward.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee no longer qualified for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from December 29, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), intraoral periapical radiographic images (x-ray) (D0220), and palliative procedure (D9110), provided on March 11, 2021.  You asked the Plan to pay for the limited oral evaluation, intraoral x-ray, and palliative procedure. You say that the services should be covered. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.  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 the limited oral evaluation (D0140), intraoral periapical radiographic images (x-ray) (D0220), and palliative procedure (D9110), provided on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341), gingival irrigation (D4921), and preventative procedure (D1999), provided on April 12, 2021.  You asked the Plan to pay for the periodontal scaling and root planing, gingival irrigation, and preventative procedure]. You say that the services were medically necessary. The Plan denied your request. The Plan says you have exceeded your benefit for the periodontal cleaning and the other services are not covered services under your benefit Plan.  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 the periodontal scaling and root planing (D4341), gingival irrigation (D4921), and preventative procedure (D1999), provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on July 27, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were told 50% would be covered and only $37.35 was applied on this bill. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan.  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 the problem focused limited oral evaluation (D0140) provided on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit with a physician (99336) provided on August 20, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for a domiciliary or rest home visit with a physician. You say that it is the nursing facility's responsibility to get authorizations for their patients. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says that these services are not urgent or emergent, nor were they 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit with a physician (99336) provided on August 20, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fluoroscopic guidance and injection services rendered on February 22, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 77003 is not supported and 64483 is not separately payable.  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 77003 is fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure). We find that CPT code 77003 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. Based on this information, we decided that Medicare rules for coverage of these services have not been met.  The rules say that post-surgical pain management services are included in the global surgical package.  Billed procedure code 64483 (injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level) is included in the global surgical package for major procedure 27279 (sacroiliac joint arthrodesis) performed on December 8, 2020. Payment for the injections is included in the payment for the major procedure.  Therefore, we decided that the Plan does not have to pay for the fluoroscopic guidance and injection services rendered on February 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90792) provided on September 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that this provider should be in-network. The Plan denied your request. The Plan says this was not authorized.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90792) provided on September 8, 2021, by an out-of-network (OON) provider.   Your complaint about the provider's network status 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: 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 based on the documentation provided the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the 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 based on the documentation provided 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.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that you almost passed out because of the lack of care at the facility. The Plan denied your request. The Plan says you clearly require physical and occupational therapy as well as pain control with medicine by mouth and management of the medicines you routinely take every day by mouth. The Plan states you do not need to be seen by a rehabilitation doctor at least three (3) times a week for evaluation of functional and medical goals and progress and you do not need an intensive team (rehabilitation doctor and nurse, social worker, and therapists) for your care. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility.  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 you are stable with no acute medical illness and does not meet Centers for Medicare & Medicaid Services (CMS) coverage criteria for an IRF admission. With your current medical stability, and no other acute medical complexity, there is no need for Physical Medicine and Rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs noted in the record. You do not need intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. Your therapy needs can be easily and safely provided in a skilled nursing facility (SNF). IRF admission is not medically necessary based on lack of medical complexity and nursing needs. Document does not support the necessity for admission to IRF. While you may benefit from continued physical therapy (PT), and occupational therapy (OT), your rehabilitation needs can be safely provided in an alternate and low intensity setting such as in an SNF.  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 IRF admission and services.