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

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on March 4, 2021, through March 15, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service 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 Each time you are admitted to an acute care hospital, you pay $300. You will not pay more than $900 for inpatient hospital covered services in a calendar year for inpatient hospital care.
You have been asked to pay $300 for inpatient hospital services. This service falls within the inpatient hospital care 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 inpatient hospital care provided on March 4, 2021, through March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).

You asked the Plan to pre-approve IMRT. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because IMRT is not medically necessary.

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 IMRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no rationale provided for the need for IMRT. Simply provided a plan comparison without providing context for need generally does not suffice in demonstrating the necessity of IMRT. The current version of National Comprehensive Cancer Network (NCCN) guidelines states that IMRT should only be used in the setting of a clinical trial, in unique clinical situations such as reirradiation, or in unique anatomical situations. As such, IMRT would not be considered furnished in accordance with accepted standards 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 IMRT have not been met. Therefore, we decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that custom functional orthotics are medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for subsequent nursing facility telehealth visit (99309-95) provided April 28, 2021.
You asked the Plan to pay for subsequent nursing facility telehealth visit. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says that the maximum number of units have been exceeded. Per Medicare claims processing manual chapter 12: subsequent nursing facility care services are limited to one telehealth visit every 14 days.
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 subsequent nursing facility services frequency limitation provided via telehealth is now 14 days, not 30 days. You can find this rule in https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf. The nursing facility code was billed with the 95 modifier which indicates this was a telehealth service. The plan did not provide any supporting documentation that another nursing facility telehealth code was billed and paid for another date of service within 14 days of the service at issue. Therefore, we decided that the Plan has to pay for subsequent nursing facility telehealth visit (99309-95) provided April 28, 2021.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from September 5, 2020, to
September 14, 2020.
You asked the Plan to pay for the inpatient care. You say that the claim should be paid under the diagnosis
related group (DRG) 252 instead of the downgraded DRG 166. The Plan denied your request. The Plan says
the records do not support the billing of the principal diagnosis of pulmonary embolism, bilateral, International
Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code I26.99.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with pulmonary embolism, bilateral, ICD-10-CM code
I26.99. 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 the inpatient care. Our reviewer says that
the principal diagnosis of pulmonary embolism, bilateral, ICD-10-CM code, I26.99 is not supported. The
review indicates that the condition most treated after study is pulmonary embolus with COR pulmonale. The
reviewer found that the enrollee presented with significant oxygen requirement, coupled with the EkoSonic
endovascular system (EKOS) procedure, makes this more about the pulmonary emboli. Therefore, the reviewer
found that the records do not support the billing of the principal diagnosis code of pulmonary embolism,
bilateral, ICD-10-CM code I26.99.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient care provided from September 5, 2020, to September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural injections.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says the records received do not include any recent clinical information about the enrollee's back pain.

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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no recent documentation of the back pain problem, or detail as to the degree and duration of the prior two injections. Therefore, the request is considered to be 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation provided on May 28, 2021.

You asked the Plan to pay for the moderate sedation. You say that the other charges on the claim were processed. You say that the documents support the services and should be reviewed. The Plan denied your request. The Plan says the original decision to deny payment is correct.

The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the technical component (TC) of radiology services furnished to hospital patients.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the moderate sedation have not been met. Specifically, CPT code 99153 is a TC only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Therefore, we decided that the Plan does not have to pay for the moderate sedation provided on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), complete series x-ray (D0210), application of fluoride varnish (D1206), and filling (D2392) provided from April 28, 2021, to May 13, 2021.
You asked the Plan to pay for the dental services. You say that the provider advised they were in network. You say that you feel that you were deceived. You also say that you should not be responsible for this bill when they gave you the wrong information. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that services are only covered when received by a participating provider. The Plan also says fluoride varnish is not a covered service.
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 oral evaluation, prophylaxis, complete series x-ray, and filling are not among those covered under this benefit when received by an out of network dentist. Additionally, fluoride varnish is not covered under this benefit regardless of the dentist's network status. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), complete series x-ray (D0210), application of fluoride varnish (D1206), and filling (D2392) provided from April 28, 2021, to May 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there were not two adequate facet diagnostic injections.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a requirement for two sets of medial branch blocks that produce 80% pain relief. The first set produced 50-60% relief and the second set produced 80% pain relief. Therefore, the request is considered 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
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 clinical documentation provided supports the
need for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care
have not been met. The Plan says that the enrollee can get the therapy services needed at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for encephalopathy, acute kidney injury, and dehydration. The enrollee's medical problems are
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. While the documentation does support a need for physical and/or occupational therapy, there
is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a LTACH for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the records do not show completion of a full course of care in the hospital.
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 there is no documentation provided indicating medical necessity for admission to a
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where he is currently receiving
care.
There are no services available at the LTACH that the enrollee requires that are not available at the health care
setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis.
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 admission to a LTACH for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device.

You asked the Plan to pay for intermittent limb compression device. You say that the items were medically necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare to prevent deep vein thrombosis during or after surgery.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a heart catheterization and ventriculography.
You asked the Plan to pre-approve a heart catheterization and ventriculography. You say that the records provided support the need for the services in dispute. The Plan denied your request. The Plan says that the services in dispute are not medically necessary
The Plan follows Medicare rules. Medicare rules say that left heart catheterization is covered for certain clinical indications and when 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 a heart catheterization and ventriculography. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee is undergoing staged two or possibly three vessel percutaneous coronary intervention (PCI) for angina and ischemic cardiomyopathy. He recently was revascularized in the left circumflex territory and the plan is to revascularize the left anterior descending (LAD) territory next. The health plan contends that full left heart catheterization and left ventriculography are not needed and that limited angiography with directed planned PCI of the LAD will suffice. However, in this instance, the enrollee has a known ischemic cardiomyopathy with decreased left ventricular ejection fraction (LVEF). He has recently been at least partially revascularized and has not had a repeat assessment of left ventricular (LV) function since the left circumflex artery (LCX) PCI was done in October 2021. A repeat assessment of LV function to evaluate any improvement in his LV function following the LCX-OM procedure is reasonable at this time and medically necessary. As he is undergoing cardiac catheterization with a plan for PCI of the LAD, left heart catheterization with ventriculography for reassessment of LV function would be medically appropriate in this specific clinical situation. It would therefore not be considered "routine" and would meet criteria "required for patient management" for this specific clinical indication (revascularization for LV dysfunction). 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 heart catheterization and ventriculography have been met. Therefore, we decided that the Plan has to pre-approve a heart catheterization and ventriculography.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the family psychotherapy services provided on April 29, 2021.
You asked the Plan to pay for the family psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that psychotherapy services are only covered when provided by a covered provider. We looked at the file and Medicare rules. Review of the file does not support that the psychotherapy services were rendered by a covered provider. Based on this information, we decided that Medicare rules for coverage of the family psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the family psychotherapy services provided on April 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiopharmaceutical localization of tumor services coded 78830 provided on January 20, 2021.
You asked the Plan to pay for the radiopharmaceutical localization of tumor services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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, we have confirmed that code 78830 for the radiopharmaceutical localization of tumor services has a bundled relationship with code 79445 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 radiopharmaceutical localization of tumor services coded 78830 provided on January 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 11, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based
on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on February 11, 2021.