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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need rehabilitation and someone to change your dressings. You say that you live in a multi-level home and need to be on blood thinners, but do not have a prescription. 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 safely receive the services needed in other settings.

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 does require physical therapy and occupational therapy, she does not require an intensive inpatient rehabilitation therapy program. Care at the skilled nursing facility level appears to be appropriate in this case. 

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 acute inpatient hospital care admission and services.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient hospital care is medically necessary. The Plan denied your request. The Plan says the requested inpatient hospital care does not meet criteria.
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 medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 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 admission and services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
April 12, 2021.

You asked the Plan to pay for procedure codes 99601 and 99602. You say that you have submitted medical 
records to justify payment. The Plan denied your request. The Plan says the procedure codes billed are not 
payable by Medicare. The Plan must follow Medicare rules. Medicare rules say that codes 99601 and 99602 are 
invalid for Medicare purposes. We looked at the file and Medicare rules. Therefore, we decided that the Plan 
does not have to pay for procedure codes 99601 and 99602 billed for date of service April 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esomeprazole Magnesium.
You asked the Plan to pre-approve self-administered drug. You say that this is a much-needed medication for
the enrollee. The Plan denied your request. The Plan says the denial of authorization for this drug is correct,
because this drug is not covered by Medicare Part B and should be covered by the enrollee's Medicare Part D
prescription drug benefits instead.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Esomeprazole Magnesium.
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care, for the enrollee.

You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from Part A therapies to be able to return to their prior level of function. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF services, they have not had a change in function that needs daily skilled therapy services, and they do not have any daily skilled nursing needs. The Plan states the enrollee's current needs can be safely managed with an alternate level of care, such as in a long-term care setting with part-time 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. 

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. This enrollee does not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis (if needed) appear appropriate in this case. 

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care, for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 the enrollee was admitted with neutropenic fever in the setting of acute myelogenous leukemia and aplastic anemia. The record indicates that the enrollee requires daily transfusion and is not medically stable. The record indicates that the enrollee requires ongoing acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.

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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from June 17,
2021 to July 16, 2021.
You asked the Plan to pay for SNF care. You say that the services are necessary. The Plan denied your request.
The Plan says based on the documentation provided, coverage criteria has not been met.
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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs and did not receive daily therapy. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical matter, could be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from June 17, 2021 to July 16, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on
August 31, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $5 copayment for each primary care physician visit for Medicare-covered benefits.

You have been asked to pay $5 for the Medicare-covered telehealth primary care physician visit provided. 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 office visit (99213) provided on August 31, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 9, 
2021 and August 7, 2021.

You asked the Plan to pay for SNF care. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met.

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 pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not have documented skilled 
nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not 
required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The 
enrollee's care needs, as a practical matter, could be provided at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from July 9, 2021 and August 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not
been met.
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 a Vertiflex device. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the vertilfex device is experimental. More research is needed to show safety and
efficacy.
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 Vertiflex device have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the high dose rate electronic
brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed (0394T) and
the therapeutic radiology simulation-aided field setting (77280) provided on July 19, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to
the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Medicare-covered in-network therapeutic radiological services.
You have been asked to pay $88.75 ($55.29 + $33.46) for the Medicare-covered in-network therapeutic
radiological services provided. This includes the Medicare-allowed amount of $276.45 x 20%
coinsurance=$55.29 for the therapeutic radiological procedure provided. This also includes the Medicare
allowed amount of $167.28 x 20% coinsurance=$33.46 for the electronic brachytherapy provided. Although
the provider in this case is an out-of-network provider with the plan, the claim was processed at the in-network
rate and the in-network cost share was applied. 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 coinsurance for the high
dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when
performed (0394T) and the therapeutic radiology simulation-aided field setting (77280) provided on July 19,
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0427, A0425) provided on July 18, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you did not authorize your transfer from one hospital to another, so you should not be responsible for this bill. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.

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 $100 copayment for ambulance services.

You have been asked to pay a $100 copayment for the ambulance transportation. The ambulance services are covered and were found to be medically necessary. 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 ambulance transportation services (A0427, A0425) provided on July 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam and ophthalmic ultrasound 
(92250, 76512) provided on June 11, 2021.

You asked the Plan to waive the copayment for an eye exam and an ophthalmic ultrasound. You say that the 
services should be covered as they would cause financial hardship. The Plan denied your request. The Plan says 
the cost-sharing applied correctly based on the services provided.

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 Outpatient diagnostic tests and therapeutic services and supplies and a $20 copayment for vision 
care. 

You have been asked to pay a $50 copayment for an eye exam and a $20 copayment for an ophthalmic 
ultrasound. Eye exams fall within the vision care benefit category, while the ophthalmic ultrasound falls within 
the Outpatient diagnostic tests and therapeutic services and supplies 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 an eye exam and ophthalmic ultrasound (92250, 76512) provided on June 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on December 15, 2020.

You asked the Plan to pay for the lab services. You say that you have provided medical records to support payment of this claim. The Plan denied your request. The Plan says you did not bill with the appropriate place of service.

The Plan must follow Medicare rules. Medicare rules say that the place of service code entered on a claim should reflect the actual setting where the patient receives the face-to-face service. In the case of lab services, the face-to-face encounter occurs during specimen collection. In this case, you billed with place of service 81, which is an independent lab. However, the records show that the patient was not physically present in your lab for the specimen collection. Rather, the specimen was collected in an office setting. As such, the office setting place of service code should have been entered on the claim. Therefore, we decided that the Plan does not have to pay for lab services provided on December 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0427, A0425) provided on March 6, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford this bill, and feel the cost is too high for the services provided. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. Ambulance services require a $150 copayment.

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 $150 copayment for each one-way ground ambulance trip.

You have been asked to pay a $150 copayment for the ambulance transportation. 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 ambulance transportation services (A0427, A0425) provided on March 6, 2021.