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

We decided that the Plan does not have to pay for the complex control of nasal hemorrhage coded as 30903 provided December 23, 2020.
You asked the Plan to pay for the complex control of nasal hemorrhage. You say that the billed procedure code is supported by the medical documentation submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for the services provided.
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 30903 is Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method. 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 complex control of nasal hemorrhage. Our reviewer says that the billed code is not supported by the medical documentation submitted. Our reviewer found the documentation does not include enough information to extensive control was performed. Documentation states "MDM patient with anterior epistaxis that was cauterized with silver nitrate". In this case, the procedure should include detailed documentation to confirm extensive control was needed. Therefore, a more appropriate code should be reported in this case. 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 complex control of nasal hemorrhage have not been met. Therefore, we decided that the Plan does not have to pay for the complex control of nasal hemorrhage coded as 30903 provided December 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the water chamber for a humidifier and foam dressings rendered on October 5, 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that one water chamber for humidifier (A7046) is covered every six months. We looked at the file and Medicare rules. The file shows that the Plan approved a water chamber for humidifier billed with code A7046 on June 30, 2020. The services billed on October 5, 2020 exceed the limit of one per
six months. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
The rules do not list the -KX modifier as an appropriate modifier for billing with procedure code A6209
The file shows that procedure code A7046 (foam dressing) was billed with modifier KX. This modifier is inappropriate for this procedure code and the services cannot be paid as billed.
Therefore, we decided that the Plan does not have to pay for the water chamber for a humidifier and foam dressings rendered on October 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.

You asked the Plan to pre-approve the SNF admission. You say that you have had a decrease in your mobility
since April 2021, and you have been receiving physical therapy and occupational therapy at home for over two
months. You also say that you were advised that you need more intensive therapy. The Plan denied your
request. The Plan says the records do not show that you are receiving therapy evaluations. The Plan also says
that the records do not show that you have had a decline in function and your level of function has been the
same since April 2021.

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 the SNF admission. Our reviewer says
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment
of a skilled professional therapist. Our reviewer also found that you do not require daily skilled nursing and/or
skilled therapy on an inpatient basis in a SNF setting.

We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs,
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of
the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF
admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on May 7, 2020 to December 30, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that you were not told you have specific vendors for supplies needed. The Plan denied your request. The Plan says only services from an in-network provider will be covered.
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 file shows that continuous positive airway pressure (CPAP) supplies were provided. The providers in this case are not a network providers with the Plan. The Plan had network providers available who could have provided the items 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 durable medical equipment provided on May 7, 2020 to December 30, 2020 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy (OT).

You asked the Plan to pre-approve occupational therapy (OT). You say that OT is medically necessary. The Plan denied your request. The Plan says OT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve OT.

Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the requested occupational therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The documentation does not demonstrate that the unique skills of a professional occupational therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy (OT) have not been met. Therefore, we decided that the Plan does not have to pre-approve OT.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is medically necessary.
The Plan denied your request. The Plan says total electric beds are denied as not reasonable and necessary
because the height adjustment feature is a convenience feature.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital
bed (E0265).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services.
You asked the Plan to pre-approve the continued home health services. The Plan denied your request. The Plan says the records do not show that you have a need for continued physical, occupational, or speech-language therapy. The Plan also says that the records do not show that you are homebound.
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 continued home health services. Our reviewer says that continued home health services are not shown to be medically necessary or reasonable for you. Our physician reviewer found you do not appear to be homebound. Our reviewer found that you do not have documented skilled nursing needs. Our physician reviewer also found that you do not have documented skilled therapy needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continued home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay the out of network rate for the extraction. We decided that the Plan does
not have to pay any additional amount for the extraction.

You asked the Plan to pay for the extraction. You say that prior to having the procedure performed, you
contacted the plan to ensure it would be covered. You say that the plan representative advised the service was
covered, the provider was out of network, and that you have out of network benefits. You also say that you do
not understand how the service can be denied after verifying it would be covered. The Plan denied your
request. The Plan says that the provider in this case has opted out of Medicare. The Plan says that payment
cannot be made to providers that have opted out of Medicare. The Plan also says that you were advised prior to
the date of service that the provider was out of network and that you have out of network benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental
service when the services are medically necessary and reasonable.

We decided that the Plan has to pay the out of network rate for the extraction.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental service have been met. The record shows that the provider in this case has opted out of
Medicare. The record shows that the Plan advised the provider was out of network and that you have out of
network benefits. There is a 55% coinsurance for extractions when performed out-of-network. Therefore, we
decided that the Plan has to pay the out of network rate for the extraction.

We also decided that the Plan does not have to pay any additional amount for the extraction.

Coinsurance is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage.
Additionally, out of network providers may bill you for any amount greater than the Plan pays to the provider.
Therefore, we decided that the Plan does not have to pay any additional amount for the extraction.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on May 20, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you are requesting full payment of the bills attached. The Plan denied your request. The Plan says you are owed an additional 53.58 but the $10 copayment still applies.
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 $10 copayment for each Medicare-covered outpatient rehabilitation service visit. You have been asked to pay a $10 copayment for the physical therapy visit. Physical therapy falls 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 waive the copayment for physical therapy provided on May 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you want additional trips to see your doctor after ankle surgery. The Plan denied your request. The Plan says that you have exceeded your benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of twenty-four (24) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on April 30, 2021 to May 5, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were never told that you would have to pay this much. The Plan denied your request. The Plan says the correct copayment has been 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 $370 copayment per day for days 1-5. There is no copayment for additional days for inpatient hospital care.
You have been asked to pay a $370 copayment per day for days 1-5. There is no copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,850 ($370 x 5 days = $1,850). An inpatient hospital stay falls 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 an inpatient hospital stay provided by a participating provider on April 30, 2021 to May 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from August 6, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from August 6, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care from August 6, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of August 6, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond August 6, 2021, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from August 6, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from August 6, 2021, forward.
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 you need inpatient rehabilitation and are not safe to return home at this time. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on April 15, 2021.

You asked the Plan to pay for physical therapy services. You say that the documents should be reviewed, and 
the claim processed toward payment. The Plan denied your request. The Plan says the records do not support 
the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a physician 
assistant, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 17, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided on March 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET imaging of whole body for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary for initial treatment strategy with newly diagnosed adenocarcinoma of the prostate. The Plan denied your request. The Plan says this is not covered for Medicare beneficiaries who have adenocarcinoma of the prostate.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 scan. Our reviewer says that the requested imaging is not medically reasonable or necessary. Our physician reviewer found PET scans have limited sensitivity in assessing nodal status in prostate cancer. PET is generally reserved for staging metastatic disease if other imaging is equivocal. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET imaging of whole body for the enrollee.