Persius/hicric huggingface dataset:
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 notes do not show that the enrollee must have an intensive therapy program in order to improve self-care functioning. The Plan states the enrollee's medical and therapy needs could be met in a skilled nursing unit.
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 respiratory failure, congestive heart failure, pulmonary edema, cardiac arrest, acute kidney injury, and encephalopathy. 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 this 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the stress test rendered on May 25, 2021.
You asked the Plan to waive the copayment for these services. You say that you are displeased with the services you received. The Plan denied your request. The Plan says the copayment was 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 $30 copayment for Medicare-covered non-radiological diagnostic services.
Review of the file shows that you received a stress test on May 25, 2021. You have been asked to pay a $30 copayment for these services. These services fall within the Medicare-covered non-radiological diagnostic 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 copayment for the stress test rendered on May 25, 2021.
Your complaint about the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography services coded 75726 and 75774 provided on May 5, 2021.
You asked the Plan to pay for the angiography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 75726 and 75774 are not supported in the medical record. Specifically, codes 75726 and 75774 are considered inclusive to code 37242, a vascular embolization or arterial occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention, to treat a condition other than hemorrhage or tumor (congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms; therefore, these codes cannot be verified. Based on this information, we decided that Medicare rules for coverage of the angiography services have not been met. Therefore, we decided that the Plan does not have to pay for the angiography services coded 75726 and 75774 provided on May 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actigraphy (95803) to rule out narcolepsy with the approved sleep studies.
You asked the Plan to pre-approve Actigraphy (95803). You say that the requested Actigraphy (95803) is medically necessary. The Plan denied your request. The Plan says the requested Actigraphy (95803) is not medically necessary.
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 Actigraphy (95803). Our reviewer says that the requested Actigraphy (95803) is not medically necessary. Our physician reviewer found the enrollee has been diagnosed with hypersomnia. A multiple sleep latency test on 10/16/18 showed one sleep onset REM period which was suggestive, but not diagnostic of, narcolepsy. On 8/20/21, the enrollee's assessment was
daytime hypersomnia of unclear etiology. Possibilities included idiopathic hypersomnia, new onset of sleep apnea or periodic limb movements of sleep, circadian rhythm disorder, medication effect, and possible depression. The documentation does not support that the requested Actigraphy is medically reasonable and necessary for the enrollee in this case. Actigraphy is not an accepted standard of medical practice and has not been shown to be at least as beneficial as existing and available medically appropriate testing modalities. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Actigraphy (95803) have not been met. Therefore, we decided that the Plan does not have to pre-approve Actigraphy (95803) to rule out narcolepsy with the approved sleep studies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on March 23, 2021 by a 
non-participating provider. 
 
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 rendered by a non-participating 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 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 the chiropractic services provided on March 23, 
2021 by a non-participating provider.
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for non-surgical management of pelvic fractures 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 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 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance services (A0428 and A0425) provided on May 4, 2021.
You asked the Plan to pay for the non-emergent ambulance services. You say that you would like reconsideration because the transportation was medically necessary. The Plan denied your request. The Plan says ambulance services are not covered for this destination.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance services. Our reviewer says that the documentation did not support that the ambulance transport was medically reasonable and necessary for the member. Our physician reviewer found the documentation did not show that other means of transport were contraindicated for this member. The documentation did not support that the member needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. 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 non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance services (A0428 and A0425) provided on May 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on July 2, 2021. 
 
You asked the Plan to pay for the services. You say that fafads The Plan denied your request. The Plan says 
this is a bundled service. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (70450) provided on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint rendered on April 26, 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 were not medically necessary.
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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a history of sacroilitis and lumbar spondylosis. The use of RFA for the treatment of SI joint pain is considered experimental and investigational in nature. The services were not 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. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint rendered on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ophthalmology services you received on July 21, 2020, and July 22, 2020.
You asked the Plan to waive the copayments for the ophthalmology services. You say that you called the provider to ask them to correct their bill and they were rude. You stated that you were billed incorrectly. The Plan denied your request. The Plan says it initially processed one of the claims for these dates of service incorrectly. They have been reprocessed and at this point you are only being charged a $40 copayment for each date of service.
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 $40 copayment for services in a specialist's office.
You have been asked to pay a $40 copayment for the ophthalmology services. The ophthalmology services fall within the services in a specialist's office 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 ophthalmology services you received on July 21, 2020, and July 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Urine PCR panel rendered on June 15, 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 urinalysis is the standard of care for urinary tract infection (UTI). We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care for the diagnosis and treatment of a UTI. 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 Urine PCR panel rendered on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement procedures you had at 
an outpatient hospital facility from March 22, 2021, to June 23, 2021. 
 
You asked the Plan to waive the copayments for the wound debridement procedures. You say that you did not 
have a copayment for these services in 2020, but now you do.  You say that these bills are too much for you. 
The Plan denied your request. The Plan says you were charged these copayments 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 procedures/surgery at an outpatient hospital.  
 
You have been asked to pay a $50 copayment for the wound debridement procedures. The wound debridement 
procedures fall within the outpatient procedures/surgery at an outpatient hospital 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 wound debridement procedures you had at an outpatient 
hospital facility from March 22, 2021, to June 23, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to waive the copayment for air ambulance services on November 2, 2019. 
 
You asked the Plan to waive the copayment for the air ambulance services. You say that the enrollee did not 
receive these services. The Plan denied your request. The Plan says that this copayment was charged 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).  
 
We looked at the contract between the enrollee and the Plan. In this case, we agree that the contract says there 
is a $265 copayment for air ambulance services.  However, the records clearly show that the enrollee expired 
prior to the air ambulance arriving at the hospital, and the enrollee was never placed in the air ambulance.  We 
also agree that there may be a payable service provided by the air ambulance company for the costs associated 
with getting the air ambulance to the hospital, that doesn't mean that the enrollee is responsible for that.  
Because the enrollee passed away before the air ambulance arrived and the transport was cancelled, the 
enrollee did not receive air ambulance services.  The enrollee could not be expected to know that a copayment 
would apply when no service was provided to them. This means that the Plan did not follow Medicare rules for 
disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for air 
ambulance services on November 2, 2019.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hemorrhoid surgery you had at an ambulatory surgery center on July 7, 2021.
You asked the Plan to waive the copayment for the hemorrhoid surgery. You say that you had authorization for this service and you used network providers. You believe you are being separately charged for the anesthesia services. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($73.96) is less than your copayment obligation, you are responsible for the full allowed 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 $225 copayment for outpatient surgery in an ambulatory surgery center.
Please note that the claim for which you are being charged this copayment is the facility claim for the surgery itself. You have been asked to pay this copayment for the hemorrhoid surgery that you had in an ambulatory surgery center 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 the hemorrhoid surgery you had at an ambulatory surgery center on July 7, 2021.
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 based upon your current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. You need physical therapy (PT) and occupational therapy (OT) in an alternate low intensity level. Documentation does not support the need for therapy program consisting of at least three (3) hours of therapy per day at least five (5) days per week with an interdisciplinary approach to rehabilitation care. IRF admission is not medically necessary. While you may benefit from PT and OT, your
rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 8, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 8, 2021.