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

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from April 1, 2021, to April 27, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you hit your out-of-pocket maximum with this claim, which is why you are only being charged $3820.05.
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 $0 copayment for days 1-20, and a $184 copayment for days 21-100 for SNF services.
Records show that you were in a SNF from March 7, 2021, to March 15, 2021, and again from March 18, 2021, to March 31, 2021, for a total of 22 days. You were not charged a copayment for the first 20 days of this stay. The last 2 days of the SNF stay you had prior to April 1, 2021, had a $184 copayment assessed. You then remained in the SNF from April 1, 2021, to April 27, 2021, for a total of 26 additional days. According to your Evidence of Coverage, you are responsible for a $184 copayment per day for each of these days, for a total of $4784. However, you only had $3820.05 remaining on your out-of-pocket maximum for the year, so that is all the Plan is charging you. 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 skilled nursing facility (SNF) services you received from April 1, 2021, to April 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a chest x-ray (71046) or for an office visit
(99214) rendered on June 9, 2021.
You asked the Plan to waive the copayments for a chest x-ray and for an office visit. You say that you were
charged a professional fee copayment and a facility fee copayment. You also say that you were told from the
beginning your only responsibility would be the office visit copayment. You also said that your deductible has
been met and you want to be refunded the $30. The Plan denied your request. The Plan says you have been
charged the correct cost sharing amount.
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 per day, per provider, for Medicare-covered x-ray services and a $15 copayment for each Medicarecovered
visit with a primary care provider (PCP).
You have been asked to pay a $30 copayment for a chest x-ray. Chest x-rays fall within the Outpatient
Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been asked to pay a
$15 copayment for an office visit. The EOC is clear that there is a $15 copayment for office visits. 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 a chest x-ray (71046) and for an office visit (99214) rendered on
June 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional occupational therapy (OT) visits.
You asked the Plan to pre-approve occupational therapy. You say that this therapy is medically necessary. The Plan denied your request. The Plan says the criteria for occupational therapy visits are not covered and are denied as not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 occupational therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was already approved by the health plan. The enrollee has had 15 previous outpatient therapy visits and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment or that the services can only be safely and effectively performed by a therapist or by or under the supervision of a therapist. The enrollee's care plan was reviewed with the interdisciplinary team. The enrollee's ongoing therapy does not require a skilled professional occupational therapist. The requested services are not part of a maintenance program, and do not require the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional occupational therapy (OT) visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility.
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 55-year-old male with a cerebrovascular accident. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from February 17, 2020, to February 29, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the documentation does not support the non-therapy ancillary (NTA) component of the PDPM score billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 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 services provided. Our reviewer found that an initial nutritional assessment noted that the enrollee was at risk for malnutrition, related to diabetes, depression, and hypertension. At that time, the enrollee was meeting her nutritional needs through oral intake, and there were no dietary changes needed. There are no additional clinical records available for review. The available clinical documentation is insufficient to support the inclusion of malnutrition/risk of malnutrition as an active diagnosis for the SNF stay at issue. 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 provided have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from February 17, 2020, to February 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) and prefabricated post and core in addition to the crown (D2954) for tooth #19.
You asked the Plan to pre-approve a crown and prefabricated post and core in addition to the crown for tooth #19. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and prefabricated post and core in addition to the crown (D2954) for tooth #19.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the knee; 4 or more views (73564) and the office visit (99204) rendered by the out-of-network (OON) provider on May 12, 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 x-ray exam of the knee; 4 or more views (73564) and the office visit (99204) rendered by the out-of-network (OON) provider on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alignable system (L5920) for a preparatory above-knee prosthesis.
You asked the Plan to pre-approve an alignable system. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item 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 an alignable system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the previously approved L5580 preparatory above-knee prosthesis is a non-alignable system. Therefore, the L5920 alignable system cannot be used with the provided preparatory prosthesis and would exceed the enrollee's medical needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an alignable system have not been met. Therefore, we decided that the Plan does not have to pre-approve an alignable system (L5920) for a preparatory above-knee prosthesis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient admission for an approved gender confirmation surgery.
You asked the Plan to pre-approve the inpatient admission. You say that this is a complex procedure and requires at least an overnight stay. The Plan denied your request. The Plan says this procedure can be provided in the outpatient setting, and admission to inpatient status can be done if there are complications which require this level of care.
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 the inpatient admission. Our reviewer
says that the documentation does not support that the criteria for inpatient coverage are met in this case. Our physician reviewer found the enrollee is a transgender female who is to undergo a planned gender confirming procedure. The provider has requested inpatient admission for this procedure, but the Plan has approved outpatient admission. The procedure is not on the Medicare inpatient-only list. There is no specific clinical rationale for the requested inpatient admission for the procedure. There is no clear documentation that the necessary hospital care will 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 the inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient admission for an approved gender confirmation surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (62323).
You asked the Plan to pre-approve a lumbar epidural steroid injection. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.
The Plan must follow Medicare rules. Medicare rules say that a LESI is covered for the diagnoses listed in the Medicare rules section of this letter. 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 lumbar epidural steroid injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the medical records provided, there is no documentation that the enrollee meets Medicare coverage criteria for administration of the requested lumbar epidural steroid injection (62323). Records do not document a recent thorough medical evaluation of the enrollee which meets all of the criteria in the Medicare rules. 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 lumbar epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (62323).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 services provided by an out-of-network provider on May 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional home health skilled nursing.
You asked the Plan to pre-approve 6 additional home health skilled nursing. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 6 additional home health skilled nursing. Our reviewer says that the services are not medically necessary. Our physician reviewer found you are noted to not be homebound. Your family is noted to be able to provide wound care. As such, the requested, ongoing, home health skilled nursing services are not medically necessary, reasonable or coverable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional home health skilled nursing have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional home health skilled nursing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) and the closed treatment of a
metatarsal fracture; without manipulation (28470) rendered by the OON provider on November 10, 2020.
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 office visit (99203) and the closed treatment of a metatarsal fracture; without
manipulation (28470) rendered by the OON provider on November 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered when specific criteria are met. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 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 these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the records show that you have a personal mobility deficit but the occupational therapy document does not show that it impairs your ability to participate in mobility-related activities of daily living (MRADLs). There are no objective medical progress notes from the nurse practitioner or physical with a detailed neuromuscular or musculoskeletal exam. You state you will use a cane or walker and want the PWC for community needs. The criteria for coverage are not met and the services are therefore not reasonable or medically 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 these services have not been met. Furthermore, the file shows that the PWC is being requested for use outside of the home, and Medicare does not cover this item for that use. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SPECT Scan (78452) provided on
July 12, 2021.
You asked the Plan to waive the copayment for a SPECT Scan. You say that the services should be covered, and you were not aware that a copay would apply. The Plan denied your request. The Plan says the copayment 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 a $50 copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $50 copayment for SPECT Scan. SPECT Scan 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 a SPECT Scan (78452) provided on July 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on February 12, 2021.
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 are not covered.
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 76856 is ultrasound, pelvic (nonobstetric), real time with
image documentation; complete.
We find that CPT code 76856 is not supported in the medical record. Specifically, there is no documentation of
a real time pelvic ultrasound (nonobstetric). Based on this information, we decided that Medicare rules for
coverage of these services have not been met.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 76856 (pelvic ultrasound) and 93976 (duplex scan of
arterial inflow). Code 93976 is a column II code with a modifier indicator of 1 when billed with column I code
76856. Code 93976 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the imaging services rendered on February 12,
2021.