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

 We decided that the Plan does not have to waive the copayment for the orthopedic surgery visit you had on August 19, 2021.  You asked the Plan to waive the copayment for the orthopedic surgery visit. You say that you feel like this should be waived because it was to check the incision from surgery. 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 orthopedic surgery visit. This copayment applies regardless of the reason for the visit. 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 orthopedic surgery visit you had on August 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric services.  You asked the Plan to pre-approve inpatient psychiatric services. You say that the enrollee is gravely disabled and cannot function at a lower level of care. You say that the enrollee cannot care for himself and is a danger to himself. The Plan denied your request. The Plan says the records do not indicate that the enrollee has any medical issues that require treatment at this level of care. The Plan says that the enrollee could be treated at a lower level of care.  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 services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on December 4, 2021, with Major Neurocognitive Disorder most likely due to Parkinson's Disease or Lewy Body Disease. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others. The enrollee was showing auditory/visual hallucinations and paranoid ideation without any aggressive behaviors while being cooperative with care. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. The enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of December 27, 2021 forward and could have been treated in a lesser restrictive 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 inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the dermatology visit you had on August 23, 2021.  You asked the Plan to waive the copayment for the dermatology visit. You say that you do not understand why you have to pay this amount. 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 $45 copayment for visits with a specialist.   You have been asked to pay a $45 copayment for the dermatology visit. The dermatology visit falls within the visits with a specialist 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 dermatology visit you had on August 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) you received on July 26, 2021.  You asked the Plan to waive the copayment for the TTE. You say that there is no billing code listed online for this service and no explanation of why the full contracted amount was not paid and why your share is $125.  You said that there is no deductible or copayment for this service, so it should have been paid in full. 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 $125 copayment for radiological diagnostic services.   You have been asked to pay a $125 copayment for the TTE. The TTE falls within the radiological diagnostic 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 transthoracic echocardiography (TTE) you received on July 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health aide services.  

You asked the Plan to pre-approve home health aide services. You say that these services are medically necessary. The Plan denied your request. The Plan says you do not meet criteria for these services.  

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our reviewer says that you do not meet coverage criteria for home health aide services. Our physician reviewer found the documentation doesn't support that you require skilled nursing services or skilled rehab services to provide treatment that is medically necessary. You do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration.   

You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. You do not require skilled care but do require custodial care that can be provided at a lower level of care.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide 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 does not meet criteria.  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 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 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 waive the copayment for inpatient hospital services you received from October 27, 2020, to November 3, 2020.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that this was the second admission to the hospital for the same issue. 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 $295 copayment per day for days 1-4 and a $0 copayment for additional days for inpatient hospital care.    Records show that you were in the hospital for seven days.  You were charged a copayment of $395 per day for each of the first four days, for a total of $1580. This cost sharing applies each time you are admitted, regardless of the reason for the admission. 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 services you received from October 27, 2020, to November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services provided on February 14, 2021, billed with codes 99152 and 93010.  You asked the Plan to pay for the medical services as billed. You say that this should be paid as billed. The Plan denied your request. The Plan says codes 99152 and 93010 are not supported.  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 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. The definition of 93010 is Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the medical services as billed. Our reviewer says that the billed codes are not supported in the record. Our reviewer found the procedure report does not document the presence of a trained observer which is required by the code definition for 99152. For 93010, no interpretation/report was present in the file to support this code.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on February 14, 2021, billed with codes 99152 and 93010.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond December 17, 2021.  

You asked the Plan to pre-approve the continued SNF care. You say that it is felt that the enrollee is not able to be discharged at this time. The Plan denied your request. The Plan says the enrollee no longer requires daily skilled services to maintain his condition.  

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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on 11/30 due to abdominal pain and a fall with subdural hematoma. He has been receiving nursing and therapy services in the SNF.  

At this time, the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond December 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on July 7, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan denied your request. The Plan says observation care would have been more appropriate.

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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record did not show 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 not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on July 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient surgery you had at an outpatient hospital facility from July 13, 2021, to July 14, 2021.  

You asked the Plan to waive the copayment for the outpatient surgery. You say that you stayed in the hospital overnight, so you should be charged an inpatient copayment, not an outpatient copayment.  You said that previous times when you had surgery and stayed overnight, you had the inpatient hospital copayment applied. The Plan denied your request. The Plan says you were not admitted to the hospital as an inpatient, so 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 $350 copayment for outpatient surgery in an outpatient hospital.   

You have been asked to pay a $350 copayment for the outpatient surgery. Your contract states that unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for outpatient surgery.  Even if you stay in the hospital overnight, you might still be considered an outpatient. In this case, you were not formally admitted to the hospital as an inpatient. 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 outpatient surgery you had at an outpatient hospital facility from July 13, 2021, to July 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

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 the enrollee appears to be more stable, however, it is not clear that the enrollee is able to be weaned at this time. The enrollee should require only short-term acute care services that can safely be administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer may be considered when treatment has completed and when a lower level of care is appropriate.

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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injection services (procedure code 64493 and 64494) provided to the enrollee on July 15, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was not billed 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 codes 64493 and 64494 is 1. The MAI value for this code is 2. You billed 4 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for injection services (procedure code 64493 and 64494) provided to the enrollee on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the annual physical exam you had with your primary care doctor on July 27, 2021.  You asked the Plan to waive the copayment for the annual physical exam. You say that neither you nor your doctor know the distinction between an annual physical and a wellness visit.  Therefore, you think the copayment for this visit should be waived. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you did not have an annual wellness visit, so the copayment 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 copayment for primary care visits.   You have been asked to pay a $20 copayment for the annual physical exam. This copayment applies any time you receive services from your primary care doctor that are not coded as annual wellness visits.  Your doctor did not bill this visit as an annual wellness visit and the records do not reflect that you had an annual wellness visit.  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. This copayment applies regardless of whether or not a physical exam may be more appropriate for you annually than a wellness exam. Therefore, we decided that the Plan does not have to waive the copayment for the annual physical exam you had with your primary care doctor on July 27, 2021.   Your complaint about not getting a $30 gift card for not having an annual wellness visit 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.