Persius/hicric huggingface dataset:
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.

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. The enrollee does not require the intensity of services provided at an IRF.

Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy with specimen collection (45378) provided on April 22, 2021.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was just a regular colonoscopy screening and should be covered. The Plan denied your request. The Plan says this colonoscopy was performed to investigate existing symptoms which required further evaluation. Therefore, this was a diagnostic colonoscopy and the surgical 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 $325 copayment for outpatient surgery services. 

You have been asked to pay a $325 copayment for the diagnostic colonoscopy. According to the provided medical records, the colonoscopy in this case was provided to investigate existing symptoms. The colonoscopy was billed with procedure code 45378, which is indicated as a diagnostic colonoscopy with a specimen collection and is classified as a surgical procedure. Therefore, the outpatient surgery copayment applies in this case. 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 diagnostic colonoscopy with specimen collection (45378) provided on April 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9328) provided April 13, 2021.
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the code billed is not eligible for payment.
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 code S9328 is not supported in the medical record. Specifically, per the National Physician
Fee Schedule, the code billed has a status of "I" which means it is invalid for Medicare payment. Based on this
information, we decided that Medicare rules for coverage of the home infusion services have not been met.
Therefore, we decided that the Plan does not have to pay for home infusion services (S9328) provided April 13,
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.

You asked the Plan to provide additional routine transportation. You say that you are legally blind and rely on this transportation to get to your appointments. The Plan denied your request. The Plan says routine transportation in excess of the maximum number of covered trips is not covered.

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 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 provide additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 15, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from October 15, 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 October 15, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of October 15, 2021, forward. Our physician reviewer found you do not require inpatient mental health treatment beyond October 15, 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 October 15, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 15, 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 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 treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a laminotomy (63030-59) provided on February 17, 2021.

You asked the Plan to pay for a laminotomy. You say that this was performed on a different level from 22633. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 

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 a laminotomy Our reviewer says that the billing of this code with modifier -59 is not supported. Our physician reviewer found the medical records provided do not include sufficient documentation to validate that 63030-59 was performed as a distinct, separate service from procedure 22633, which was performed on the same date of service, by the same physician in the same operative session. 

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 laminotomy have not been met. Therefore, we decided that the Plan does not have to pay for a laminotomy (63030-59) provided on February 17, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance service, advanced life support, emergency transport,
level 1 (A0427), and the ground mileage (A0425) provided on May 21, 2021.

You asked the Plan to pay for the ambulance services. You say that the enrollee's claim was sent to the correct
plan. You also say that this claim should be paid. The Plan denied your request. The Plan says that you are
listed as the enrollee's secondary insurance carrier. The Plan says that it has been verified with the enrollee's
primary insurance carrier that there is a claim for these services, and it has been paid. The Plan also says that
the claim was processed correctly.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. We find that the Plan did not provided documentation that would substantiate
their claim that they are not the enrollee's primary insurer. Therefore, we decided that the Plan has to pay for
the ambulance service, advanced life support, emergency transport, level 1 (A0427), and the ground mileage
(A0425) provided on May 21, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87532, 87541, 87581, 87640, and 87798 provided on September 21, 2020.
You asked the Plan to pay for the laboratory 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 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. We find that CPT codes 87486, 87496, 87498, 87532, 87541, 87581, 87640, and 87798 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a nursing facility place of service 32. Based on this
information, we decided that Medicare rules for coverage of the laboratory services have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496,
87498, 87532, 87541, 87581, 87640, and 87798 provided on September 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 19, 2021, to
April 21, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was admitted electively
for surgery. The Plan denied your request. The Plan says inpatient admission was not authorized due to the
procedure that was scheduled for the enrollee was cancelled. The Plan also says services were approved for
observation only.
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 does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found that the enrollee was initially brought into the hospital for an inpatient procedure. The
procedure was not performed, and the visit turned into an emergency department visit. The enrollee was
cleared and discharged on the same day. The record did not show that at the time of inpatient admission the
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency
department 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 not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided April 19, 2021, to April 21, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on May 12, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you were told to go to the ER because of a lab result. You say when you went to the ER, they re-ran your blood work and everything was fine. The Plan denied your request. The Plan says you were charged this copayment 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 $90 copayment for visits to the emergency room. You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason
for the ER visit. 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 emergency room (ER) visit you had on May 12, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services (12011) and electrocardiogram (93010) provided on December 9, 2020.

You asked the Plan to pay for the surgery services and electrocardiogram. You say that you would like these claims reprocessed based on the medical documentation. The Plan denied your request. The Plan says these claims have denied correctly.

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 12001 is simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less.

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 surgery services and electrocardiogram. Our reviewer says that the medical documentation does not support the surgery services billed as 12011. Our reviewer found the procedure report documents "Normocephalic, 2.5 cm linear laceration to the occipital region. No active bleeding. No foreign bodies. No tenderness or crepitus. There is left periorbital ecchymosis with mild edema". A more appropriate code should be reported for this service CPT 12001 due to laceration of scalp. 

We looked at this coder's review, the file, and Medicare rules. In this case, we have confirmed that the documentation did not support code 12001 as billed. Therefore, the provided service is not eligible for coverage. In addition, we have confirmed that the electrocardiogram coded as 93010 has a bundled relationship with code 12001 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Based on this information, we decided that Medicare rules for coverage of the surgery services and electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services (12011) and electrocardiogram (93010) provided on December 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) provided
on February 25, 2021.
You asked the Plan to pay for the non-emergency ambulance transport. The Plan denied your request. The Plan
says ambulance transport to or from an outpatient office or facility for a scheduled appointment is not a
Medicare covered benefit.
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-emergency ambulance transport.
Our reviewer says that the documentation does not support that the ambulance transport was medically
reasonable and necessary for the enrollee. Our physician reviewer found the documentation does not support
that other means of transport (such as stretcher van) were contraindicated for this enrollee on February 25,
2021. Our reviewer also found that the documentation does not support that the enrollee needed the expertise,
services and lifesaving and life-sustaining equipment that only a fully equipped ambulance could provide for
safe transport on February 25, 2021. The enrollee was stable and did not require treatment during 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-emergency ambulance transport have not been met. Therefore, we
decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) provided on
February 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional physical therapy visits.
You asked the Plan to pre-approve 4 additional physical therapy visits. You say that you require the full 12 visits to assist with chronic back pains and fibromyalgia. You say that the 12 visits will be very helpful in restoring your health. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.e 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 4 additional physical therapy visits. 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 outcome of the additional therapy is not yet documented, and you should be able to be instructed in a home exercise program with the already authorized therapy. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional physical therapy visits.
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 can handle and would benefit from the intensive level of services provided at an IRF. You are getting weaker in the hospital and want to regain your prior level of function as quickly as possible. 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.