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

We decided that the Plan does not have to waive the copayment for the urgent care telehealth visit you had on May 12, 2021.
You asked the Plan to waive the copayment for the urgent care telehealth visit. You say that the doctor at the urgent care was very rude and condescending. You said that you believe this charge is unfair. The Plan denied your request. The Plan says you were charged this cost sharing 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 $50 copayment for urgently needed services. You have been asked to pay a $50 copayment for the urgent care telehealth visit. This copayment applies regardless of your satisfaction with the service you received. 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 urgent care telehealth visit you had on May 12, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on April 7, 2020.

You asked the Plan to pay for the psychiatric diagnostic evaluation. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 a psychiatric diagnostic evaluation provided on April 7, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an implantable cardioverter defibrillator (ICD).

You asked the Plan to pre-approve the requested services. You say that antiarrhythmics have been limited due to symptomatic bradycardia. The Plan denied your request. The Plan says that the coverage requirements have 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 requested services. Our physician reviewer found that the enrollee has as cardiac amyloidosis and a reported history of non-sustained VT. His EF is moderately reduced, and he has other risk factors for sudden death including late gadolinium enhancement on the MRI scan. He requires a pacemaker due to bradycardia when he is treated with anti-arrhythmics for his AF. Given the baseline amyloid heart disease (genetic disorder with high risk for life-threatening tachyarrhythmias) along with the above noted enhanced risk factors for sudden cardiac death (NSVT, late enhancement), he would therefore meet the medical necessity as well as the specific criteria for ICD implantation as a part of the planned pacemaker insertion therapy. 

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 been met. Therefore, we decided that the Plan has to pre-approve an implantable cardioverter defibrillator (ICD).

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits you had with an orthopedic surgeon on April 27, 2021, and May 5, 2021.
You asked the Plan to waive the copayments for the orthopedic surgery visits. You say that you had three visits for knee injections. You said that you were told that you only had to pay the copayment for the first visit, not one for each visit. The Plan denied your request. The Plan says you were charged these copayments 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 $30 copayment for each specialist visit. You have been asked to pay a $30 copayment for the orthopedic surgery visits. Your Schedule of Copayments explicitly states that you pay this copayment for each visit, regardless of the services received. 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 office visits you had with an orthopedic surgeon on April 27, 2021, and May 5, 2021.
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 April 1, 2021, to April 5, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you had to be 
transferred from one facility to another in order to receive more appropriate care for your condition.  You stated 
that since the two facilities are affiliated, the second admission should not be considered a separate admission, 
but a continuation of the first admission. 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 $300 
copayment per day for days 1-6, and a $0 copayment for days 7 and beyond per admission for inpatient 
hospital care.  
 
You have been asked to pay a $300 copayment per day for the inpatient hospital services. Records show that 
you were discharged from the first facility and admitted to a second facility. According to your Evidence of 
Coverage, inpatient hospital care starts the day you are formally admitted to the hospital.  You had two separate 
admissions, so two copayment periods apply.  This is true even if the facilities are affiliated. 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 April 1, 2021, to April 
5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care billed with a secondary diagnosis code of acute kidney failure with tubular necrosis (N17.0) provided from December 23, 2020, to December 31, 2020.

You asked the Plan to pay for the inpatient hospital care. You say that the secondary diagnosis code that was billed with this inpatient hospital services were correct. The Plan denied your request. The Plan says the documentation does not support the secondary diagnosis code as billed.

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 N17.0. 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 hospital care. Our reviewer says that the medical documentation does not support the secondary diagnosis of acute kidney failure with tubular necrosis (N17.0). Our physician reviewer found that the hospital correspondence maintained N17.0 was a valid diagnosis for this encounter, as acute tubular necrosis was supported by provider documentation, evidence within the record, and met criteria as an additional diagnosis per the Uniform Hospital Discharge Data Set (UHDDS) criteria. However, review of the medical record supports an admission for further evaluation and treatment of a left, displaced, closed, peri trochanteric hip fracture for which a cephalo- medullary nailing was performed. While an uncertain diagnosis of "likely ATN", was noted in the Nephrology consultant and progress notes, subsequent provider documentation was unclear and/or inconsistent regarding this condition. Nephrology consultant progress notes document on the day of discharge, "acute kidney injury, back to baseline renal function". The discharge summary documentation includes acute kidney injury (AKI) with chronic kidney disease (CKD) 3 in the diagnostic list without mention of acute tubular necrosis. The documentation is unclear and inconsistent regarding a diagnosis of ATN. The review has determined that the medical records did not support the billed secondary diagnosis code N17.0.

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 hospital care billed with a secondary diagnosis code of acute kidney failure with tubular necrosis (N17.0) provided from December 23, 2020, to December 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services provided on April 1, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and the rules. We find that CPT codes 99601 and 99602 are not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion services provided on April 1, 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 enrollee needs LTACH care to fully recover and successfully regain maximum independence. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.

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 that there is no documentation provided indicating medical necessity for admission to an 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on May 24, 2021.

You asked the Plan to pay for the testing services. You say that you have no knowledge of enrollee coverage prior to the specimen's arrival. The Plan denied your request. The Plan says the codes are not covered.

The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the beneficiary's medical documentation.

We looked at the file and the rules. We find that the testing at issue is not supported in the medical record. Specifically, the records provided do not show that the testing was ordered due to the enrollee's history, clinical assessment, including medication side effects or inefficacy, suspicious behaviors, self-escalation of dose, doctor-shopping, indications/symptoms of illegal drug use, evidence of diversion, or other clinician documented change in affect or behavioral pattern. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on May 24, 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 you need time to build muscle. The Plan denied your request. The Plan says you do not have any skilled needs at this time.

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 you are at a supervision level for standing up, transfers and toilet transfers. You require supervision for walking using a rolling walker. You do not have any skilled nursing or therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pharmacogenomic testing provided on June 7, 2021.

You asked the Plan to pay for pharmacogenomic testing. You say that the results of this testing allow physicians to most effectively make treatment decisions for patients. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing panel should be billed with a single unit of miscellaneous test code 81479.

The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple reportable test results, only a single procedure code shall be reported. 

We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of pharmacogenomic testing have not been met. Therefore, we decided that the Plan does not have to pay for pharmacogenomic testing provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on April 21, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 subsequent nursing facility care (99308) provided on April 21, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the surgical extraction (D7210) and inhalation of nitrous oxide/analgesia (D9230) provided on May 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay more for the surgical extraction and inhalation of nitrous oxide/analgesia. You say that you cannot pay this bill. The Plan denied your request. The Plan says this claim paid benefits up to the allowed amount for these services that were rendered by an OON provider.

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, you are responsible for the difference between the billed amount and allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan does not have to pay more for the surgical extraction (D7210) and inhalation of nitrous oxide/analgesia (D9230) provided on May 17, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies provided on January 11, 2021.

You asked the Plan to pay for the services provided. You say that the claim was not processed in accordance with the standards. The Plan denied your request. The Plan says no separate payment is made for this service.

The Plan must follow Medicare rules. Medicare rules say that for bundled procedures, payment for covered services is always bundled into payment for other services not specified.

In this case, the CPT Code Manual definition of code 99072 is Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. 

We find that CPT code 99072 is a bundled service. When this service is covered, payment is subsumed by the payment for the services to which they are incident Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lumbar or sacral diagnostic injection (64493, 64494, and 64495), and anesthetic injection (64451).

You asked the Plan to pre-approve the lumbar or sacral diagnostic injections, and anesthetic injection. You say that the service is medically necessary. The Plan denied your request. The Plan says you have not tried or failed a recent trial of conservative therapy which includes physical therapy.

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 lumbar or sacral diagnostic injections, and anesthetic injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that performing radiofrequency ablation on the lateral sacral branches is considered experimental/ investigational because of the wide variation in efficacy described in the literature.

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 lumbar or sacral diagnostic injections, and anesthetic injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the lumbar or sacral diagnostic injection (64493, 64494, and 64495), and anesthetic injection (64451).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of an intrauterine device (IUD).

You asked the Plan to pay for IUD removal. You say that the reason this was removed was because it was causing a chronic infection. The Plan denied your request. The Plan says the denial of payment for this service is correct, because reversal of a sterilization procedure is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing conception (contraception) are not considered medically reasonable and necessary. Your contract with the Plan says that reversal of sterilization procedures is not covered under any conditions. 

Records show that the requested service is primarily for the purpose of removal of a contraceptive device. The documentation does not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for removal of an intrauterine device (IUD).