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

 We decided that the Plan does not have to pay for the skilled nursing services provided from August 25, 2021, to September 23, 2021.  You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive skilled therapy or skilled nursing care during these dates and was functioning at her baseline.  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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 25, 2021, to September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the application of a modality to 1 or more areas; electrical stimulation (unattended) (CPT code 97014) provided to the enrollee on March 29, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says this service is not covered.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. CPT code 97014 is assigned a status code I = Not valid for Medicare purposes. Therefore, this service is not covered. Therefore, we decided that the Plan does not have to pay for the application of a modality to 1 or more areas; electrical stimulation (unattended) (CPT code 97014) provided to the enrollee on March 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the coinsurance for an office visit provided on February 12, 2021.  You asked the Plan to waive the coinsurance for office visit. You say that you were told this service would be covered. The Plan denied your request. The Plan says that the claim was paid correctly, and the correct amount was applied.  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 enrollees must pay a $0 copayment for Provider and Professional Services in a PCP's Office or a Specialist's Office.   The Plan says you must pay a 20% coinsurance for office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for office visit. Therefore, we decided that the Plan has to waive the coinsurance for an office visit provided on February 12, 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: 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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.  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 patient was admitted for slurred speech, weakness and chronic back pain managed with a thoracic lumbar sacral orthosis (TLSO) brace. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for eye surgery performed on September 13, 2021, and September 27, 2021.  You asked the Plan to waive the copayments for the eye surgery. You say that you had the procedures at an ambulatory surgical center instead of an outpatient hospital. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $275 copayment for outpatient hospital surgery visits.   You have been asked to pay a $275 copayment for each eye surgery, for a total of $550. The billing code from the provider reflects an outpatient hospital facility, not an ambulatory surgical center. The eye surgery falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for eye surgery performed on September 13, 2021, and September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral exam (D0120) provided on September 17, 2021.  You asked the Plan to pay for the dental service. You say that the plan allows for cleanings twice a year, every 6 months. You say that your first cleaning was on March 10, 2021. You also say that the denied cleaning was clearly performed more than 6 months later. The Plan denied your request. The Plan says oral exams are covered twice per plan year. The Plan says that the frequency limit has been exceeded. The Plan also says that the cleaning (prophylaxis) for this date of service was paid.  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 and oral exam is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for oral exams that you received on June 22, 2021, and July 28, 2021. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) provided on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to fully pay for the lower partial denture (D5214) provided on June 22, 2021.  You asked the Plan to fully pay for the lower partial denture (D5214). You say that the new dentures do not work, and you want a refund. The Plan denied your request. The Plan says the claim processed correctly.  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 copayment of $385 for a lower partial denture (D5214). Therefore, we decided that the Plan does not have to fully pay for the lower partial denture (D5214) provided on June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance angiography, head; without contrast material(s) (CPT code 70544) provided to the enrollee on September 14, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  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 70544 is a column II code to column I code 70551. 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 magnetic resonance angiography, head; without contrast material(s) (CPT code 70544) provided to the enrollee on September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the mandibular partial denture (D5214) and surgical extraction (D7210) and to pay more for the maxillary partial denture (D5213) provided on July 12, 2021.  You asked the Plan to pay for the mandibular partial denture and surgical extraction or pay more for the maxillary partial denture. You say that you were advised the enrollee would have to pay nothing for the dentures. You also say that the enrollee was never advised they only had a $1,000 limit for the year. The Plan denied your request. The Plan says reimbursement meeting the enrollee's annual dental maximum has already been issued by the Plan.  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 Plan offers a $1,000 annual dental benefit maximum. The record shows that the enrollee met the annual maximum benefit while processing this claim for the July 12, 2021 date of service and the enrollee's annual maximum benefit has been exhausted.  Therefore, we decided that the Plan does not have to pay for the mandibular partial denture (D5214) and surgical extraction (D7210) and to pay more for the maxillary partial denture (D5213) provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for dialysis provided from July 21, 2021, to July 30, 2021  You asked the Plan to waive the coinsurance for dialysis. You say that the coinsurance applied is very high. The Plan denied your request. The Plan says the proper coinsurance was 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 20% coinsurance for Medicare-covered renal dialysis. The total amount allowed for each dialysis dates was $247.37 with the coinsurance being $49.47 ($247.37 total amount x 20% coinsurance). With a total of five days of dialysis the total coinsurance was $247.35 ($49.47 coinsurance daily x 5 days).    You have been asked to pay a 20% coinsurance for dialysis. Dialysis falls within the Services to treat kidney disease 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 coinsurance for dialysis provided from July 21, 2021, to July 30, 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 you need IRF care in order to return home safely and maintain your independence. Without the rehab you will end up back in the hospital. 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 in 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 the occupational therapy evaluation (97167) provided on January 14, 2021.   You asked the Plan to pay for the occupational therapy evaluation (97167). You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.  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 97167 is a column II code to column I code G0238. 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 occupational therapy evaluation (97167) provided on January 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 871.  You asked the Plan to pay for the inpatient hospital services billed with DRG 871. You say that the diagnosis is fully supported by the medical record and obvious clinical indicators. You also say that the principal diagnosis was correct, and the secondary diagnoses were supported as well. The Plan denied your request. The Plan says that DRG 871 is not supported as the diagnosis.  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 DRG 871. 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 hospital services billed with DRG 871. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found the medical records did not support the billing of DRG 871.   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 billed with diagnosis related group (DRG) code 871.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the arthrodesis (22554) provided on December 19, 2020.  You asked the Plan to pay for the arthrodesis (22554). You say that the medical records should be reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says procedure 22554 billed on December 19, 2020, is included within the global surgery package of procedure 22600 billed on December 17, 2020.  The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the arthrodesis (22554) have not been met. Specifically, there is no indication this service is unrelated to the previous procedure. Therefore, we decided that the Plan does not have to pay for the arthrodesis (22554) provided on December 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for pump assembly, blood salvage, and red blood cells provided to a hospital inpatient on June 14, 2021.  You asked the Plan to pay for nonphysician services. You say that under ancillary provider rules, you are requesting payment for these services that were requested by the participating surgeon and facility. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services must be furnished directly by the hospital or billed through the hospital under arrangements.  The Plan must follow Medicare rules. Medicare rules say that nonphysician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.   We looked at the file and Medicare rules. These services must be furnished directly by the hospital or billed through the hospital under arrangements. Based on this information, we decided that Medicare rules for coverage of nonphysician services have not been met. Therefore, we decided that the Plan does not have to pay for pump assembly, blood salvage, and red blood cells provided to a hospital inpatient on June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can walk 10-20 feet, as well as stand and shift weight.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there is no documentation that the enrollee meets criteria for the multiple power option feature, power tilt/recline and elevating leg rests. Provided records do not document muscle spasticity, the need for intermittent bladder catherization or a high risk for skin breakdown to qualify for the tilt/recline feature. The records do not document edema to qualify for the power leg elevation feature. The enrollee may meet criteria for a group 3 power wheelchair with no power options.   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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
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 LTACH services are medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. It is not safe for the enrollee to leave the hospital this time because they have an unstable acute brain disorder. The enrollee is receiving appropriate care in the hospital, and there is no advantage in transferring to an LTACH at this time. The enrollee can stay in the hospital until they are safe for transfer or discharge.  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 there is no documentation provided indicating medical necessity for LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care.  There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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.