Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the myocardial perfusion imaging, tomographic (SPECT) service (78452) provided on May 13, 2021.

You asked the Plan to waive the deductible for the SPECT. You say that you met your deductible on March 29, 2021, and the deductible should not have been applied to this service. The Plan denied your request. The Plan says you had not me the deductible prior to the date in question. $219.57 was applied to your deductible, at which point you satisfied the $500 amount. Then you were responsible for your copayment for this service, and the Plan paid their share of the cost.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible which applies to other outpatient radiological diagnostic services. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category other outpatient radiological diagnostic services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to outpatient diagnostic services. We reviewed the documentation provided and found that while you did pay an amount of $500 or more for services prior to this date, and this amount was applied to your out-of-pocket total, the services provided are not ones to which the deductible applies. Your deductible does not apply to all medical services, and documentation shows that the amounts previously paid were coinsurance or copayment costs rather than deductible amounts. The record shows that you paid $35.72 toward your deductible in April of 2021, and then you paid another $244.71 on the date in question. After you paid $219.57 for this service, you had met your 2021 deductible. This means you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation that had not been met at the time the SPECT was received on May 13, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the myocardial perfusion imaging, tomographic (SPECT) service (78452) provided on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing (99080, U0002, 99199) provided April 2, 2021 in Taiwan.
You asked the Plan to pay for the lab testing in Taiwan. You say that the services were required to re-enter the United States. The Plan denied your request. The Plan says the services were not emergent or medically necessary and are non-covered.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. The testing was not for medical reasons and was performed for travel purposes. Based on this information, we decided that Medicare rules for coverage of the lab testing in Taiwan have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (99080, U0002, 99199) provided April 2, 2021 in Taiwan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says only 40-50% improvement in pain was achieved.
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than four (4) diagnostic joint sessions will be reimbursed per rolling 12 months, in recognition that the pain generator cannot always be identified with the initial and confirmatory diagnostic procedure. 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 as the enrollee has already had at least four previous medial branch blocks at the requested levels bilaterally, a fifth procedure would not be considered reasonable or necessary. Additionally, the last injection only achieved 40-50% improvement in pain based on the enrollee's questionnaire. 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 facet joint injections for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from October 9, 2021, forward.
You asked the Plan to pre-approve SNF care. 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 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 the enrollee no longer qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can 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 pre-approve continuation of SNF care from October 9, 2021, forward.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0427, A0425) provided on April 27, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you disagree with the mileage charge because you 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 $270 copayment for ambulance services. You have been asked to pay a $270 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 emergency ambulance transportation services (A0427, A0425) provided on April 27, 2021.
In your appeal you indicated that you disagreed with the mileage cost listed under the "charges" column of the statement you submitted for appeal. Please note that you are not liable for this amount. You are only responsible for your $270 copayment as listed under the "patient responsibility" column of this statement.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the muscle and/or fascia debridement (11043), subcutaneous tissue debridement (11042), and the chemical cauterization of granulation tissue (17250) 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 muscle and/or fascia debridement (11043), subcutaneous tissue debridement (11042), and the chemical cauterization of granulation tissue (17250) rendered by the out-of-network (OON) provider on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 21, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a nursing facility setting and
should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is necessary for you to regain some mobility or 
else your doctor will not approve knee surgery. The Plan denied your request. The Plan says the stay is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 have a past medical 
history of knee osteoarthritis, diabetes, hypertension and obesity and is living at home with ongoing weakness 
and knee pain. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two (2) skilled nursing visits (CPT code G0299 X 2)
and three (3) physical therapy visits (CPT code G0151 X 3) for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says your records do not support the need for a skilled physical therapist to make more home
visits and your records do not support the need for a skilled nurse to make more visits.
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 the services. Our physician reviewer
found the health plan's denial should be upheld. The enrollee does not have documented skilled nursing needs
(i.e. IVs, complex wound care, new ostomy). The enrollee does not have documented skilled therapy needs.
The enrollee is non-ambulatory and lives in a facility with caregivers available to help. As such, the requested,
ongoing, home health services are not medically necessary or reasonable.
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 two (2) skilled nursing visits (CPT code G0299 X 2) and three (3) physical therapy visits
(CPT code G0151 X 3) 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 there is no documentation provided indicating medical necessity for the requested LTACH services. 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 they are 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 LTACH services.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve occupational therapy services.
You asked the Plan to pre-approve occupational therapy services.. You say that failure to achieve maximal benefits from therapy will result in poor outcome and a greater chance for you to be reliant on help for activities of daily living. The Plan denied your request. The Plan says that you still have moderate pain after ongoing treatment from your therapy provider. The Plan states this therapy is no longer reasonable, effective and/or needing a skilled therapy provider. The Plan states you still have severe activity restrictions after ongoing treatment from your therapy provider. The Plan states this therapy is no longer reasonable, effective and/or needing a skilled therapy provider.
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. It appears that the plan's contracted delegate was provided the records for this admission and has failed to forward them to support the decision to deny based on no medical necessity. Therefore, we decided that the Plan has to pre-approve occupational therapy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. 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 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 Coronavirus pneumonia. 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve Vertiflex. You say that this procedure is considered safe and effective and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this procedure is correct, because Vertiflex is experimental/investigational.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0426, A0425) provided on April 15, 2021.
You asked the Plan to pay for ambulance services. You say that this was medically necessary. The Plan denied your request. The Plan says the enrollee was an inpatient at the time of service, meaning the hospital is responsible for payment of this service.
The Plan must follow Medicare rules. Medicare rules say that all items and nonphysician services, including transportation, furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.
We looked at the file and Medicare rules. The record shows that the enrollee was an inpatient on the date of service at issue, meaning the hospital is responsible for payment of this service. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0426, A0425) provided on April 15, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the second chest x-ray interpretation provided on April 28, 2021.
You asked the Plan to pay for radiologic examination, chest; single view (71045) interpretation. You say that
the enrollee had multiple procedures. The Plan denied your request. The Plan says that they did not make a
decision in time.
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 find that CPT code 71045-26 is supported in the medical record. Specifically, the records show a second
interpretation was performed by this provider. Based on this information, we decided that Medicare rules for
coverage of radiologic examination, chest; single view (71045) interpretation have been met. Therefore, we
decided that the Plan has to pay for the second chest x-ray interpretation provided on April 28, 2021.