Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power options and accessories.
You asked the Plan to pre-approve a group 2 power wheelchair with multiple power options and accessories. You say that the requested power wheelchair is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage of the requested device have not been met.
The Plan follows Medicare rules. Medicare rules say that a group 2 power wheelchair with multiple power options is subject to the criteria listed 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 a group 2 power wheelchair with multiple power options and accessories. Our reviewer says that the requested group 2 power wheelchair with multiple power options is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 70-year-old female with a past medical history of diabetes, hypertension, multiple joint osteoarthritis, lower extremity weakness and limited ambulation. A group 2 power wheelchair with multiple power options and accessories has been requested. Based on the medical records provided there is no documentation that the enrollee meets all of the coverage criteria for the power tilt seat system. Records do not document that the enrollee is at high risk for development of a pressure ulcer in an area that is in contact with the seating surface and is unable to perform a functional weight shift or she utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed or the power seating system is needed to manage increased tone or spasticity. As the enrollee does not require the power tilt seating system or a ventilator, the requested group 2 power wheelchair with multiple power options is not medically reasonable and 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 a group 2 power wheelchair with multiple power options and accessories have not been met. Since coverage cannot be provided for the wheelchair, the requested accessories will be denied at this time. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power options and accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from April 2, 2021, through April 7, 2021, billed with secondary diagnosis code U07.1.
You asked the Plan to pay for the inpatient services as billed. You say that the enrollee had a positive test for COVID at admission which justifies reporting this as a secondary diagnosis for this hospital stay. The Plan denied your request. The Plan says reporting this diagnosis when no specific treatment for COVID was required is not appropriate and incorrectly increased DRG payment.
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 secondary diagnosis code U07.1, defined as COVID-19. 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 services as billed. Our reviewer says that the inclusion of code U07.1 as a secondary diagnosis is not supported by the records. Our physician reviewer found the enrollee was admitted 4/2/201 for surgery for anal cancer. She had a nasal swab on admission which was positive for COVID-19. She was evaluated by Infectious Disease and cleared for surgery. On 4/3, she underwent diverting loop sigmoid colostomy. She was treated with IV fluids, pain control and ostomy care. She received no treatment for COVID-19. The review has determined the documentation to support the inclusion of U07.1 (COVID-19) as an additional diagnosis for this inpatient admission. 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 the inpatient hospital services provided from April 2, 2021, through April 7, 2021, billed with secondary diagnosis code U07.1.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on February 27, 2021.
You asked the Plan to pay for the therapeutic procedure. 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 payable.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that the services billed were performed by a physical therapist assistant in a home health or hospice setting.
This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on February 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services rendered on June 14, 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 a clinical psychologist must have a referral and consult from the beneficiary's primary care physician. We looked at the file and Medicare rules. The file shows that there was no documentation of a consultation with the enrollee's primary care physician. 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 outpatient mental health services rendered on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on April 23, 2021.
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says the Plan does not offer reimbursements for hearing aids or services purchased out-of-network.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided from any network hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by a network hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on April 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram coded 93010 provided on December 7, 2020.
You asked the Plan to pay for the electrocardiogram. 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 separately payable.
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 93010 for the electrocardiogram is a column II code to column I code 12011. 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 electrocardiogram coded 93010 provided on December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the medical eye exam you received from an out-of-network provider on June 9, 2021.
You asked the Plan to waive the deductible for the medical eye exam. You say that this claim was for your annual eye exam which should be covered. The Plan denied your request. The Plan says you were charged this amount against your deductible correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible which applies to vision care services (except for diabetic eye exams and eyewear). We looked at the records in this case. The records do not show that you received a routine eye exam. The records show that you received a medical eye exam because you were evaluated for cataracts. Medical eye exams count towards your annual deductible. You had not met your annual deductible at the time you received these services. This cost sharing is a contractual obligation that had not been met at the time the medical eye
exam was received on June 9, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the medical eye exam you received from an out-of-network provider on June 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital admission provided from March 5, 2021, through March 26, 2021.
You asked the Plan to pay for a hospital admission. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 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 a hospital admission provided from March 5, 2021, through March 26, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of previous root canal therapy provided on June 18, 2021.
You asked the Plan to pay for the retreatment of previous root canal therapy. You say that the clinic checked your insurance and said this was covered. You say that you don't have money to pay this bill and the provider and Plan should be responsible. The Plan denied your request. The Plan says reimbursement has already been issued for endodontic therapy.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of one root canal procedure per calendar year. The Plan paid for the root canal provided on February 3, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the retreatment of previous root canal therapy provided on June 18, 2021.
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 May 13,
You asked the Plan to pay for the physical therapy services. You say that the medical records required to
reprocess the denied claim are attached. The Plan denied your request. The Plan says the records do not support
the code billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (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 the physical therapy services have not been met. Specifically, the billing provider is a nurse
practitioner, 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 May 13,
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on July 7, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit. You say that you provided urgent/emergent care in the home and prior authorization is not required. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the home visit provided on July 7, 2020, by an out-of-network (OON) provider.
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 an IRF admission should be covered. The Plan denied your request. The Plan says the enrollee does not meet criteria for an IRF admission.
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 the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 27, 2021, through
May 30, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that
the care received could have been administered safely and adequately in an observation care setting.
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 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 that the enrollee was brought to the emergency department (ED) after a suspected, but not
witnessed, seizure in his assisted living facility. During evaluation in the ED he had a witnessed seizure. He
was admitted with diagnoses of syncope, new onset seizure, leukocytosis with a plan for Keppra loading and a
neurology consultation. The admitting physician documented an expectation that medically necessary care
would span two or more midnights, and such care did span two or more midnights. The record show that at the
time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital
care (including earlier ED 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from May 27, 2021, through May 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing services you
received on April 26, 2021.
You asked the Plan to pay for the periodontal scaling and root planing services. You say that you were never
told that this service would not be covered. The Plan denied your request. The Plan says these services are not
covered under your dental 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
periodontal scaling and root planing services you received on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth visit provided on June 17, 2021, by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for the telehealth visit. You say that the service is medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the telehealth visit provided on June 17, 2021, by
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomics panel provided on April 28, 2021.
You asked the Plan to pay for the testing services. You say that the enrollee's specimen was drawn at the physician's office and forwarded to the lab. The Plan denied your request. The Plan says the claim was processed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. If a single procedure is performed, only one code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics panel provided on April 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from February 2, 2020, through 
February 6, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism. 
 
You asked the Plan to pay for inpatient services provided from February 2, 2020, through February 6, 2020 
with the reported principal diagnosis A41.9, sepsis, unspecified organism. The Plan denied your request. The 
Plan says this condition did not qualify for reporting. 
 
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 principal diagnosis A41.9, sepsis, unspecified 
organism. 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 inpatient services with the reported 
principal diagnosis A41.9, sepsis, unspecified organism. Our reviewer says that the documentation does not 
support that the inpatient care is payable as billed. Our physician reviewer found that the documentation does 
not support primary diagnosis of sepsis, as the treatment and care of sepsis is not documented in the provider 
documentation submitted. There is no mention of sepsis while in the emergency department that was 
documented, as well as the discharge summary documenting sepsis during hospital stay. The documentation 
supports pneumonia. Sepsis cannot be confirmed 
 
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 services provided from February 2, 2020, through February 6, 2020 with the reported principal 
diagnosis A41.9, sepsis, unspecified organism.