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 enrollee will need a hospital level of care for rehabilitation. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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. While the enrollee may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 

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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room (ER) visit you had on November 24, 2020, and the inpatient hospital services you received from December 10, 2020, to December 18, 2020.
You asked the Plan to waive the copayments for the ER services and inpatient hospital services. You say that you also have military insurance, so you were under the impression you do not pay any copayments. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that you must file these claims and explanations of benefits that the Plan has issued with your military insurer if you want them to cover the copayments.
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 $90
copayment for emergency room visits and a $235 copayment per day for days 1-7 for inpatient hospital care. You have been asked to pay a $90 copayment for the ER services and a $235 per day copayment for the first 7 days of your inpatient hospital 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 copayments for the emergency room (ER) visit you had on November 24, 2020, and the inpatient hospital services you received from December 10, 2020, to December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation provided on April 13, 2021.

You asked the Plan to pay more for the prophylaxis and periodic oral evaluation. You say that you spent two hours on the phone trying to deal with this bill. You say that the coverage makes no reference it will only pay a specific amount for each out-of-network service. The Plan denied your request. The Plan says the claim processed correctly.

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 Plan is only obligated to pay the allowed amount for a prophylaxis and periodic oral evaluation from an out-of-network provider. You are responsible for the remaining amount above what the Plan pays. Therefore, we decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation provided on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new group 2 standard power wheelchair.

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 item must be unable to be repaired or at least five years old.

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 wheelchair is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate that the current power wheelchair is over five years old. The documentation does not indicate that the current wheelchair cannot be repaired.

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 new group 2 standard power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the
requested level of care 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 that 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.

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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for physical therapy.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on January 26, 2021.
You asked the Plan to pay for the refraction. You say that you have already paid $45 to the provider. You say that you expected the $45 would be paid between the two Plans. The Plan denied your request. The Plan says the billed code is not covered under your medical benefits and is not covered when received from an out-of-network physician.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a refraction only when performed with a routine eye exam from a network provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Specifically, a medical eye exam was billed which does not include a refraction. Therefore, we decided that the Plan does not have to pay for the refraction provided on January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided to the enrollee on January 6,
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 the Medicare rules for payment of this claim have not been followed.

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 the denied codes is:

CPT 19285:

Placement of breast localization device(s)

HCPCS A9520:

Technetium tc-99m tilmanocept, diagnostic, up to 0.5 millicuries

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 services. Our reviewer says that the services at issue in
this case were not supported by the medical records. Our reviewer found A9520 has a Medically Unlikely Edit
(MUE) of 1 unit. A9520 was submitted with a total of 2 units for date of service January 6, 2021, which did not
meet the Unit guidelines per the Outpatient Hospital Services MUE, therefore, this service is not eligible for
payment. As A9520 was not eligible for payment, 19285 is also not eligible for payment.

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 services have not been met. Therefore, we decided that the Plan does not
have to pay for outpatient services provided to the enrollee on January 6, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an AtriClip placement procedure (33999) provided October 21,
2020.

You asked the Plan to pre-approve the AtriClip placement. You say that the procedure was medically
necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 the AtriClip placement. Our reviewer
says that the requested services are considered medically reasonable and necessary in this case. Our physician
reviewer found in this instance since the enrollee required thoracoscopic surgery for lead placement, the
AtriClip was both a reasonable and indicated adjunct at the time of surgery to lower her stroke risk in the
setting of a contraindication to anti-coagulation therapy. The AtriClip has both published data and FDA
approval for use in this clinical situation.

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 AtriClip placement have been met. Therefore, we decided that the Plan has
to pre-approve an AtriClip placement procedure (33999) provided October 21, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99285) provided on December 27, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is 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 99285 is "Emergency department visit for the evaluation
and management of a patient, which requires these 3 key components within the constraints imposed by the
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high
severity and pose an immediate significant threat to life or physiologic function."
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 services. Our reviewer says that the use of code 99285 is not supported by the records provided. Our reviewer found that Documentation does not support this level of service. To report a level of service for emergency department services; 3 of 3 key components must be met or exceeded. In this case for history (HPI 1 condition = brief, ROS 9 systems = complete, PFSH past medical
history, social history = complete); for exam (11 total organ systems reviewed = comprehensive); medical
decision making (presenting problem - new problem to examiner; additional workup planned = extensive), diagnostic procedures ordered (labs, radiology, IV - 3 = multiple), medical decision making is of moderate
complexity (presenting problem - acute uncomplicated illness/injury = low; diagnostic labs, xray, IV = multiple), and management options IV fluids without additives = Low).
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (99285) provided on December 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
guidelines have not been met.
The Plan must follow Medicare rules. Medicare rules say that treatment of chronic venous insufficiency is only
covered under certain medical indications.
We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the
coverage criteria listed in the rules have been met. 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 sclerotherapy services
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a nebulizer (E0570) provided on July 10, 2020.

You asked the Plan to pay for a nebulizer. You say that this was filed timely. The Plan denied your request. The Plan says that the documentation supplied did not support adjustments.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided any information on or documentation of the initial denial reasoning. Therefore, we decided that the Plan has to pay for a nebulizer (E0570) provided on July 10, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (82542, 84228, G0480, 80307) rendered by the out-of-network (OON) provider on May 18, 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 (82542, 84228, G0480, 80307) rendered by the out-of-network (OON) provider on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided on December 3, 2020 by a non-participating provider.

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 the services were rendered by a non-participating 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 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 the eye exam provided on December 3, 2020 by a non-participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for ringers lactate infusion (J7120) provided on March 20, 2021.

You asked the Plan to pay for the ringers lactate infusion. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the 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 J7120 is ringers lactate infusion, up to 1000 cc. 

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 ringers lactate infusion. Our reviewer says that CPT code J7120 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that Ringers lactate infusion, up to 1000 cc was provided on March 20, 2021, therefore, this service cannot be verified. 

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 ringers lactate infusion have not been met. Therefore, we decided that the Plan does not have to pay for ringers lactate infusion (J7120) provided on March 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
March 11, 2021, through March 12, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says an inpatient admission was not medically necessary and reasonable.
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 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 emergency department 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 the acute inpatient hospital care provided from March 11, 2021, through
March 12, 2021.