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

We decided that the Plan does not have to waive the copayment for a specialist office visit (99202) provided on May 26, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as you feel they caused you more problems. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for Physician/Practitioner services, including doctor's office visits.

You have been asked to pay a $30 copayment for the specialist office visit. The record indicates that the services were rendered by an otolaryngology specialist, 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 a specialist office visit (99202) provided on May 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital discharge day management services coded as 99239 provided on July 6, 2021.  You asked the Plan to pay for the hospital discharge day management services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the documentation does not support the services 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 99239 is hospital discharge day management; more than 30 minutes.  We find that CPT code 99239 is not supported in the medical record. Specifically, the medical documentation does not support that more than 30 minutes were spent on the hospital discharge day management service.s Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services coded as 99239 provided on July 6, 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 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 the enrollee appears to not be stable enough for transfer at this time. Acute care services can be safely administered at the current facility for the time being until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not require services at the LTACH that are not already available 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.  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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 22 to August 3, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 22 to August 3, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says that you no longer require skilled services.  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.  The file shows that continued SNF services beyond January 7, 2022, were requested. 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 continued services. Our physician reviewer found that you do have documented skilled nursing needs. You are receiving intravenous antibiotics through January 26, 2022.  You also have documented skilled therapy needs. You are not yet shown to be safely ambulating household distances, or to have reached a plateau in function. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your condition. You previously failed home-based therapy, and there is no evidence that a more effective outpatient treatment program has been arranged. Your care needs, as a practical matter, are not shown to be achievable at a lower level of care. Therefore, continued services are 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 continued services have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a cold cap provided on April 15, 2021. 
 
You asked the Plan to pay for a cold cap. You say that the item at issue was a necessity for your care. The Plan denied your request. The Plan says rules for payment have not been met. 

 The Plan must follow Medicare rules. Medicare rules say that no separate charge for scalp-hypothermia devices will be recognized.  

 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a cold cap have not been met. Specifically, the request is for payment for a separate charge for a scalp-hypothermia device. Therefore, we decided that the Plan does not have to pay for a cold cap provided on April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from March 7, 2021, to March 16, 2021.
You asked the Plan to pay for inpatient hospital care. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for this inpatient stay is correct, because the incorrect number of inpatient days was billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that for inpatient hospital care Medicare does not count the day of discharge for cost report purposes unless the admission and discharge day are the same day. As a result, the billed number of claimable Medicare patient days for an inpatient hospital stay should not include the discharge date. We looked at the file and Medicare rules. You billed 10 days of inpatient hospital care. However, this inpatient stay lasted from March 7, 2021, to March 16, 2021, which should only be billed as 9 days of inpatient hospital
care because Medicare does not count the day of discharge when billing. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from March 7, 2021, to March 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 1, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapist on June 3, 2021.

You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contract providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that services of a physical/occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a physician assistant. As such, occupational therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapist on June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient hospital care provided.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a lumbar microdiscectomy and will need inpatient admission after surgery The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 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 enrollee is approved for a lumbar microdiscectomy. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 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 pre-approve acute inpatient hospital care provided.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve spinal cord stimulator revision with battery placement.  

You asked the Plan to pre-approve the requested services. You say that given his limitation, the enrollee has not been able to utilize his stimulator. The Plan denied your request. The Plan says the revision would be for convenience.  

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 requested services. Our physician reviewer found that the enrollee has failed back surgery syndrome and is status post bilateral shoulder surgeries. He had a spinal cord stimulator device placed and the device is working well. However, the battery was placed where he is having trouble reaching it and he needs his wife to help him. The request is to reposition the device so that he can charge it himself. This request would be for the convenience of the enrollee. Therefore, the request is deemed not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal cord stimulator revision with battery placement.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
 
 You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does not need daily skilled services that can be provided only on an inpatient basis.
  
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 physician reviewer found that the enrollee is at a moderate assist level for sitting up and scooting, and minimal to moderate assist for sitting. The enrollee does not have documented skilled nursing or therapy needs. The enrollee is not shown to have had an acute decline in function. Daily skilled services are not shown to be 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a wheelchair (K0005) and accessories.
  .
You asked the Plan to pre-approve a wheelchair and accessories. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the items are not medically necessary.  

The Plan follows Medicare rules. Medicare rules say that an ultra lightweight manual wheelchair (K0005) is covered for a beneficiary if criteria (1) or (2) is met and (3) and (4) are met:

      The beneficiary must be a full-time manual wheelchair user. 
     
The beneficiary must require individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a K0001 through K0004 manual wheelchair.     

 The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features (see Documentation Requirements section). The LCMP may have no financial relationship with the supplier.      

The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient.     

 If the manual wheelchair base is not covered, then related accessories will be denied as not reasonable and necessary.  

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 a wheelchair and accessories. Our reviewer says that the service is not medically necessary. Our physician reviewer found there are no clear activities that the enrollee does that could not be accomplished in a standard manual wheelchair.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a wheelchair (K0005) and accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 85025) rendered by the out-of-network (OON) provider on May 21, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (36415, 80053, 85025) rendered by the out-of-network (OON) provider on May 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that it would be difficult to go home without getting rehab first. The Plan denied your request. The Plan says you do not require skilled therapy until your weight bearing status changes.  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 physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and was treated for pain. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a modified independent to minimal assist level for functional mobility. You required varying assist with activities of daily living. You remain non-weightbearing to your lower left extremity. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) 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 the enrollee only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available 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.  

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services (76770 and 76705) provided on August 1, 2021.

You asked the Plan to pay for codes 76770 and 76705. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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, we have confirmed that codes 76770 and 76705 are column II codes to column I code 93976. This claim has not been billed with appropriate modifiers to bypass the edits. 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 services (76770 and 76705) provided on August 1, 2021.