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

We decided that the Plan does not have to pay for imaging services (procedure code 75710) provided to the enrollee on December 1, 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 denied code is inclusive to another billed code.

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 37231 is a column II code to column I code 37231. 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 imaging services (procedure code 75710) provided to the enrollee on December 1, 2020.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The enrollee's care needs can be met at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the anticoagulation management services you received from a cardiologist's office on July 29, 2021.  

You asked the Plan to waive the copayment for the anticoagulation management services. You say that you are being charged every week and you are not going into the office. You said that you were told you would not have to pay a copayment. 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 ($10.23) 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 $35 copayment for services with a specialist.   

You have been asked to pay a $35 copayment for the anticoagulation management services. Because the results of your home monitor are reviewed by the cardiologist's office, it means that the anticoagulation management services fall within the services with a specialist 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 anticoagulation management services you received from a cardiologist's office on July 29, 2021.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  

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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation.  Your care needs can be met at a lower level of care.  

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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the sleep study you had at an outpatient hospital facility on September 11, 2021.  You asked the Plan to waive the copayment for the sleep study. You say that you should not have to pay a copayment for this because it was a follow-up from a previous sleep study.  You said that you only pay $25 for the prior one. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan also stated that you were assessed a $275 copayment for the prior sleep study as well.  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 for diagnostic procedures/tests performed in an outpatient hospital facility.   You have been asked to pay a $275 copayment for the sleep study. The sleep study falls within the diagnostic procedures/tests performed in an outpatient hospital facility benefit category. This copayment applies each time you have this service, regardless of whether or not it is related to a previous service.  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 sleep study you had at an outpatient hospital facility on September 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740), core build up (D2950), filling (D2331), sales tax (D9985), periapical x-ray (D0220), and nitrous oxide (D9230) provided on December 17, 2020.

You asked the Plan to pay for the dental services. You say that the enrollee was advised by a plan representative that the services would be covered. The Plan denied your request. The Plan says the crown, core build up, filling, nitrous oxide, and sales tax are not listed as covered service. The Plan says 1 dental x-ray is covered per calendar year. The Plan also says the frequency limit has been exceeded.

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 crown, core build up, filling, nitrous oxide, and sales tax are not among those covered under this benefit. Additionally, the record shows that the full allowed amount has been paid for the periapical x-ray. Therefore, we decided that the Plan does not have to pay for the porcelain crown (D2740), core build up (D2950), filling (D2331), sales tax (D9985), periapical x-ray (D0220), and nitrous oxide (D9230) provided on December 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart.  You asked the Plan to pre-approve the CT scan. You say that the requested CT scan is medically necessary. The Plan denied your request. The Plan says there are no new recurrent, or worsening symptoms that suggest the patient may have decreased blood to their heart muscle (cardiac ischemia)>  The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found the local coverage determination enumerates the conditions and limitations of coverage and states, in relevant part that these tests are never covered for screening, i.e., in the absence of signs, symptoms or disease. In this case, the record indicates that the enrollee is symptom free.   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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the urgent care visit you had on February 20, 2021, the x-ray you had on July 15, 2021, the magnetic resonance imaging (MRI) you had on August 4, 2021, and the podiatry visit you had on August 5, 2021.  You asked the Plan to waive the copayments for the urgent care visit, the x-ray, the MRI, and the podiatry visit. You say that you cannot afford these copayments. 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 urgent care services, a $30 copayment for x-rays, a $100 copayment for diagnostic radiology, and a $50 copayment for podiatry services.   You have been asked to pay a $50 copayment for the urgent care visit, a $30 copayment for the x-ray, a $100 copayment for the MRI, and a $50 copayment for the podiatry visit. This means that you have been asked to pay the correct amounts 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 the urgent care visit you had on February 20, 2021, the x-ray you had on July 15, 2021, the magnetic resonance imaging (MRI) you had on August 4, 2021, and the podiatry visit you had on August 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the colonoscopy with biopsy procedure you had at an outpatient hospital facility on August 13, 2021.  You asked the Plan to waive the deductible for the colonoscopy with biopsy. You say that you want this bill to be covered. The Plan denied your request. The Plan says you were assessed this 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 $1250 deductible which applies to outpatient surgery services.   We looked at the medical records in this case.  The records show that during this colonoscopy, you had a 3mm polyp removed from your sigmoid colon.  The polyp was sent to pathology for analysis. The Plan contract says that there is no cost sharing for screening colonoscopies.  However, when a screening colonoscopy becomes a diagnostic procedure (e.g., results in a biopsy or removal or lesion or growth), then outpatient cost sharing and deductibles apply.   That is the case here.  Since you had a polyp removed, the outpatient surgery cost sharing applies.  Your contract says that the deductible applies to outpatient surgery.  You had not yet met your deductible at the time of this procedure. Therefore, we decided that the Plan does not have to waive the deductible for the colonoscopy with biopsy procedure you had at an outpatient hospital facility on August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for morphometric analysis (procedure code 88374) provided to the enrollee on March 1, 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 this claim exceeds the medically unlikely edits (MUE).  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 88374 is "Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each multiplex probe stain procedure."  We find that CPT code 88374 is not supported in the medical record. Specifically, the units billed exceed the MUE for CPT 88374. 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 morphometric analysis (procedure code 88374) provided to the enrollee on March 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection procedure you had at an ambulatory surgery center on June 17, 2021.

You asked the Plan to waive the copayment for the injection procedure. You say that you had this same service in April with no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you had this injection at a different facility type in April.

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 $200 copayment for outpatient surgery and services at an ambulatory surgery center. 

You have been asked to pay a $200 copayment for the injection procedure. This copayment applies regardless of what you may have been charged in the past. 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 injection procedure you had at an ambulatory surgery center on June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve scleral contacts.  You asked the Plan to pre-approve scleral contacts. You say that you have chronic dry eye from a corneal transplant, so this is needed. The Plan denied your request. The Plan says these items are only approved for a diagnosis of keratoconus.  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 scleral contacts. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that you a corneal transplant and have dry eyes. The record does not indicate a current condition of keratoconus.  The record provided is insufficient to establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of scleral contacts have not been met. Therefore, we decided that the Plan does not have to pre-approve scleral contacts.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the records provided support the medical necessity of LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with acute hypoxic respiratory failure from COVID-19 pneumonia in the setting of receiving chemotherapy for metastatic prostate cancer.  The record indicates that the enrollee requires acute care services for ongoing pulmonary issues and anemia.  The enrollee continues to receive acute care services, and these have not been denied.  The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to your level of fatigue and weakness with therapy. Care at the skilled nursing facility level appears to be appropriate in this case.       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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  

You asked the Plan to pre-approve the SNF admission. You say that it is felt that a SNF stay would be beneficial for this enrollee's recovery. The Plan denied your request. The Plan says the enrollee does not currently require daily skilled services. Home health care should be sufficient.  

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 daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted on 12/9/2021 for a lung resection due to cancer. This was complicated by post-operative respiratory distress. The patient needed intubation from 12/11/21 to 12/16/21. The patient is now on nasal cannula. He has made good progress in therapy with improved gait distance and mobility.   

The patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 you do not require the intensity of services provided at an IRF.  Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care.  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.