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

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 24, 2020, to July 27, 2020.  

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was adjusted.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    

In this case, you billed the inpatient services provided with DRG 872 (SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC) The plan adjusted to DRG 690 (KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC). 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. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the review indicates that the documentation supported an admission for pneumonia. The documentation was inconsistent regarding a diagnosis of sepsis. Even though sepsis is documented in the history and physical, progress notes, and discharge summary, supporting medical record documentation was not found within the record. While the presentation warranted consideration of sepsis as a diagnosis, there was no evidence of life-threatening organ dysfunction due to a dysregulated host response to infection. There is no evidence of significant physiologic instability. Therefore, the medical record received and available for review does not support the condition treated as consistent with a systemic infectious process. The review has determined that DRG 690 is correct in this case.   

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 24, 2020, to July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) and supplies rendered on February 20, 2021 to June 4, 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 there is no valid

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that a standard written order (SWO) is required for all durable medical equipment. 

We looked at the file and Medicare rules. There is no valid SWO for these services in the documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.

Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) and supplies rendered on February 20, 2021 to June 4, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided from October 14, 2020, through October 20, 2020, and the radiation therapy services provided from November 19, 2020, through December 21, 2020, while outside of the United States.

You asked the Plan to pay for the inpatient hospital services and the radiation therapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 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, the Plan's contract, and Medicare rules. The Plan contract says you are covered for emergency care and urgently needed care world-wide. The file shows you were on a trip to Greece when you started bleeding. You visited a gynecologist who performed a biopsy, and you were diagnosed with endometrial cancer while out of the country. Due to COVID, you were not able to travel back to the United States. You received inpatient services where you received a complete hysterectomy followed by radiation therapy while in Greece. Medicare says that an emergency is defined as when a prudent layperson would believe that without immediate medical attention there would be serious jeopardy to his or her health. The rules say that urgently needed services are those needed because of an unforeseen illness or condition, and it is not reasonable to get the services from the plan. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services and the radiation therapy services have been met. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from October 14, 2020, through October 20, 2020, and the radiation therapy services provided from November 19, 2020, through December 21, 2020, while outside of the United States.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on December 31, 2020, and January 1, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that the services should be covered as you were told a copayment waiver would apply. 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 $275 copayment per day for Inpatient hospital care.

You have been asked to pay a $275 copayment for one day of inpatient hospital services. There were no Plan guidelines in place that state inpatient hospital copayments would be waived in 2020. Inpatient hospital services fall within the Inpatient hospital 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 inpatient hospital services provided on December 31, 2020, and January 1, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency room (ER) services rendered on  January 21, 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. The rules say that services with status indicator N are paid under the OPPS, but their payment is packaged into payment for a separately paid service.        We looked at the file and Medicare rules. The billed services have an OPPS status indicator of N and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services (procedure code 00813) provided to the enrollee on May 21, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says when multiple surgical procedures are performed during a single anesthesia administration, only the single anesthesia code with the highest Base Unit Value is reported.  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 00813 is "Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum."  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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found two "provider remittance advice documents" were reviewed. For both claims CPT 0081 (31 units) were billed. In, this case per documentation, provider submitted two claims for the same service, same patient which results in duplicate billing.  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 have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (procedure code 00813) provided to the enrollee on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental implants provided on July 16, 2021 from an out of network provider.  You asked the Plan to pay for the dental services. You say that this procedure is covered in your insurance policy. Please process this claim as an out of network claim and live up to the contractual agreement. The Plan denied your request. The Plan says dental implants are not covered under the Plan benefits.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, page 79 of the health Plan contract specifically lists dental implants as not covered. Therefore, we decided that the Plan does not have to pay for dental implants provided on July 16, 2021 from an out of network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for inpatient hospital care provided June 3, 2021 to June 6, 2021.  You asked the Plan to pay for the inpatient hospital care. You say that the inpatient services were correctly billed. The Plan denied your request. The Plan says that DRG 292 more accurately describes the services rendered.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with DRG 291. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital care. Our reviewer says that the records provided support DRG 291. Our physician reviewer found the enrollee presented with dyspnea and received BiPAP as well as diuresis. The documentation is sufficient to support a diagnosis of acute hypoxic respiratory failure.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient hospital care provided June 3, 2021 to June 6, 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for ambulance response and treatment, no transport (A0998) provided on May 4, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. You say that you had a seizure at work and your manager called the ambulance. You say when the ambulance arrived, you were feeling better, and your blood pressure was checked, and another test was done and did not get in the ambulance. The Plan denied your request. The Plan says there is a $50 copayment for treat and no transport services.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The contract with the Plan says the Plan covers ambulance services with a $50 copayment for treat and no transport services.  The ambulance company did not provide transport services on May 4, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare does not pay for the services provided. However, the Plan offers additional coverage for ambulance services with a $50 copayment for treat and no transport services. Therefore, we decided that the Plan does not have to pay an additional amount for ambulance response and treatment, no transport (A0998) provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sinus surgery to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the OON sinus surgery. You say that the records provided support the need for the requested service. The Plan denied your request. The Plan says there are available otolaryngologists in the enrollee's network who can provide the surgery needed.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve sinus surgery to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on July 30, 2021.  You asked the Plan to pay an additional amount for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the claim has processed correctly under the Medicare Plan and the balance should be processed under Medicaid.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   We looked at the file and the Plan's rules. The file shows that the balance for the ambulance services should be processed under Medicaid. Therefore, we decided that the Plan does not have to pay an additional amount for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on July 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a nuclear stress test (78452, J2785, 93017, A9502) provided April 26, 2021.  You asked the Plan to pay for a nuclear stress test. You say that services were provided in good faith. The Plan denied your request. The Plan says prior authorization was not obtained for these services.  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 a nuclear stress test (78452, J2785, 93017, A9502) provided April 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 

You asked the Plan to pre-approve SNF services. You say that you are unable to walk more than a few assisted steps and still need extensive physical and occupational therapy. You say that you are unable to get out of bed or do more than feed yourself. You say that you still have a Foley catheter due to being unable to get up and go to the bathroom. The Plan denied your request. The Plan says the continuation of SNF care 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the enrollee required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of January 26, 2022, the enrollee did not require any skilled nursing or rehabilitation services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs.) The enrollee did not require skilled therapy to establish a safe and effective maintenance program.  As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of January 26, 2022. The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved; however, his functional improvement had plateaued by January 26, 2022, and he did not require any further inpatient skilled rehabilitation services. The enrollee's function was at or near his new level of function and he could be discharged to a lower level of care for further services.  As of January 26, 2022, the enrollee required custodial services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for electrical stimulation (G0283) neuromuscular reeducation (97112) Injection of drug/substance under skin or into muscle (96372) unclassified drugs (J3490) compounded drug, not otherwise classified (J7999) thiamine injection (J3411) pyridoxine injection (J3415) and vasopneumatic devices (97016) provided on August 26, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the outpatient services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says these services are not Medicare covered benefits. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered. 

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. 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. 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. 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 electrical stimulation (G0283) neuromuscular reeducation (97112) Injection of drug/substance under skin or into muscle (96372) unclassified drugs (J3490) compounded drug, not otherwise classified (J7999) thiamine injection (J3411) pyridoxine injection (J3415) and vasopneumatic devices (97016) provided on August 26, 2021 by an out-of-network (OON) provider.