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

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the enrollee cannot be discharged home because of the enrollee's condition. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  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 does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prescription drugs (J8499) and non-prescription drugs (A9150) provided on April 1, 2021.  You asked the Plan to pay for the prescription drugs and non-prescription drugs. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says these services are statutorily not covered and are causing the whole claim to deny.  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 Medicare rules. In this case, J8499 has a Payment Status Indicator of E1 under the Hospital Outpatient Prospective Payment System. This indicator means that this code is not paid by Medicare when submitted on an outpatient claim. In addition, A9150 has a Payment Status Indicator of B. This means that this code is not recognized by the Outpatient Prospective Payment System. These codes are causing the entire claim to reject for payment and must be resubmitted. Based on this information, we decided that Medicare rules for coverage of the prescription drugs and non-prescription drugs have not been met. Therefore, we decided that the Plan does not have to pay for the prescription drugs (J8499) and non-prescription drugs (A9150) provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for podiatry services provided from May 25, 2021, to August 24, 2021.  You asked the Plan to waive the copayments for the podiatry services. You say that you feel that you should not have any copayments for the services. 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 $35 copayment for each specialist visit for podiatry services.   The file shows you had three podiatry visits from May 25, 2021, to August 24, 2021. You have been asked to pay a $35 copayment for each visit for the podiatry services, for a total of $105. The podiatry services fall within the Podiatry Services 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 copayments for podiatry services provided from May 25, 2021, to August 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 99212-25, 96372 x 4, 97150-GP, J3490-G, J3490-KP x 2, and 97139-GP provided on March 24, 2021.  You asked the Plan to pay for the outpatient therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says as non-covered services, they are not a benefit when ordered by either a contracted or a non-contracted provider in any plan design.  The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient therapy services have not been met. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. Additionally, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Lastly, the office visit at issue was billed with modifier 25, which is used to report a significant, separately identifiable Evaluation and Management (EM) service by the same physician or other qualified health care professional on the same day of a procedure or other service. There is no documentation of any significant, separately identifiable evaluation unrelated to the treatment provided to the enrollee on this date of service." Therefore, we decided that the Plan does not have to pay for procedure codes 99212-25, 96372 x 4, 97150-GP, J3490-G, J3490-KP x 2, and 97139-GP provided on March 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a debridement of subcutaneous tissue (11042) provided on May 14 and May 28, 2021, at an outpatient hospital.  You asked the Plan to waive the copayment for a debridement of subcutaneous tissue. You say that the applied copayment is an outrage or mistake. The Plan denied your request. The Plan says the correct copayment was applied.  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 $400 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.   You have been asked to pay $800, or a $400 copayment per instance for two instances of a debridement of subcutaneous tissue. A debridement of subcutaneous tissue falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 debridement of subcutaneous tissue (11042) provided on May 14 and May 28, 2021, at an outpatient hospital.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for long term hospice care provided from August 1, 2021, through August 31, 2021.   You asked the Plan to pay for long term hospice care. The Plan denied your request. The Plan says procedure code T2046 is not valid for Medicare purposes.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for long term hospice care provided from August 1, 2021, through August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for introduction of a needle/intracatheter provided on June 28, 2021.  You asked the Plan to pay for needle/intracatheter introduction. You say that this service was filed for the left common femoral artery, but all other interventions were performed on the right lower extremity so this should not be bundled. The Plan denied your request. The Plan says the denial of payment for this code is correct, because code 36140 is considered inclusive to code 37229.  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 36140-51-LT is introduction of needle or intracatheter, upper or lower extremity artery.  We asked our coder 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 needle/intracatheter introduction. Our reviewer says that this code does not meet the criteria for separate payment. Our reviewer found the operative report describes services were performed through the same puncture site. If the diagnostic angiography was performed from the same vessel access as the intervention, the vessel access is included in the code describing the intervention.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle/intracatheter introduction have not been met. Therefore, we decided that the Plan does not have to pay for introduction of a needle/intracatheter provided on June 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve Intracept. You say that significant clinical and diagnostic patient-specific data supports medical necessity. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not shown that this is helpful for treatment of the enrollee's condition.  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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental for low back pain, more research is needed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the rules for IRF care have 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 that the patient was admitted for. surgical management of a hip fracture and medical management of a lumbar fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for medical expenses incurred from April 3, 2021, to June 3, 2021.  You asked the Plan to reimburse you for medical expenses. You say that these expenses should be covered. The Plan denied your request. The Plan says sufficient information about these expenses has not been received.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. The submitted information did not include records or itemized bills to show the specific services provided. Based on this information, we decided that Medicare rules for coverage of medical expenses have not been met. Therefore, we decided that the Plan does not have to reimburse you for medical expenses incurred from April 3, 2021, to June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 28, 2021, to August 4, 2021.

You asked the Plan to pay for the acute inpatient hospital care. You say that you would like this claim to be reconsidered for coverage. The Plan denied your request. The Plan says that the enrollee's condition did not meet the medically necessary criteria for the acute inpatient hospital 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 pay for the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record did show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 28, 2021, to August 4, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on September 12, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you left the ER and returned and were admitted on your second visit. 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 $120 copayment for each emergency room visit. 

The file shows that you were initially discharged from the ER, and you had to return shortly after. This constitutes two separate ER visits, however you were only charged for one visit. Therefore, you have been asked to pay a $120 copayment for the first ER visit. The ER visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on September 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on June 10, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that you are appealing the decision based on the medical necessity to have these medical services provided in order for your doctor to review necessary laboratory work and to refill your medications. The Plan denied your request. The Plan says there are no records of a prior authorization being obtained from the member's primary care provider (PCP) prior to services being rendered on June 10, 2021.

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 an office visit (99213) provided on June 10, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from October 22, 2020, to October 31, 2020, and outpatient rehabilitation (rehab) services provided from October 27, 2020, to November 3, 2020.

You asked the Plan to pay for the SNF care and outpatient rehab services. You say that the SNF care was discontinued as you were not making progress. You say that your doctor's orders were for zero weightbearing. You also say that you feel the services should not have been discontinued. The Plan denied your request. The Plan says the claims were processed correctly.

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. The rules also 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 $40 copayment per day for each Outpatient rehabilitation services. 

The file shows that you were issued a Notice of Medicare Non-Coverage form advising that October 21, 2020 would be your last covered date of service for the SNF stay. The record does not show that you received daily skilled services after October 21, 2020. Additionally, you have been asked to pay $40 copayment per day for each outpatient rehab service. Outpatient physical therapy and outpatient occupational therapy services fall within the Outpatient rehabilitation services 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 pay for the skilled nursing facility (SNF) care provided from October 22, 2020, to October 31, 2020, and outpatient rehabilitation (rehab) services provided from October 27, 2020, to November 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99222) provided on August 24, 2021.

You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says two evaluation and management services were reported on the same day by the same provider.

The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. 

We find that CPT code 99222 is not supported in the record. Specifically, the record shows that two evaluation and management services were reported by the same physician on the same date of service. The record does not indicate that these evaluation and management services were for unrelated problems. Based on this information, we decided that Medicare rules for coverage of the initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99222) provided on August 24, 2021.