Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from November 23, 2020, through December 2, 2020 billed with secondary diagnosis code J96.01.  You asked the Plan to pay for the inpatient care as billed. You say that it is felt that the secondary diagnosis is supported and that the billed DRG should be reimbursed. The Plan denied your request. The Plan says the DRG has been adjusted as secondary diagnosis J96.01 is not supported in the record.  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 J96.01, defined as acute respiratory failure with hypoxia. 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 care as billed. Our reviewer says that the records provided do not support the use of J96.01 as a secondary diagnosis code for this admission. Our physician reviewer found there is no documentation that the secondary diagnosis code J96.01 (acute respiratory failure with hypoxia) for the inpatient hospital services provided to the enrollee from 11/23/2020 through 12/02/2020 is supported with clear physician documentation as well as reasonable support through clinical data and treatment as required by the official guideline. A letter from the appellant was included in the records available to this reviewer but no other primary medical records were provided to show clear support for the diagnosis code J96.01.    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 care provided from November 23, 2020, through December 2, 2020 billed with secondary diagnosis code J96.01.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit received on June 21, 2021.  

You asked the Plan to pay for the services. You say that this should be partially reimbursed. The Plan denied your request. The Plan says this was provided by a non-participating and non-certified provider.  

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office visit received on June 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on August 13, 2021.

You asked the Plan to waive the copayment for the lab services. You say that you do not pay copayments when having services performed. 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 $10 copayment for lab services. 

You have been asked to pay a $10 copayment for the lab services. 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 lab services you received on August 13, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for office visit services (procedure code 99213) provided to the enrollee on September 2, 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 that a diagnosis code which meets medical necessity for this procedure code is missing or invalid.  

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. The plan has not substantiated their denial. The plan has not fully clarified exactly which codes are at issue in this case. The plan has not fully clarified the denial reason in this case, as they have not stated what kind of diagnosis codes are needed in order for the claim to be covered. Therefore, we decided that the Plan has to pay for office visit services (procedure code 99213) provided to the enrollee on September 2, 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: 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 April 19, 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 April 19, 2021.
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 April 28, 2021.  

You asked the Plan to waive the copayment for the anticoagulation management services. You requested a reconsideration of the amount due. 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. 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 April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the injections provided on December 8, 2020.  

You asked the Plan to waive the coinsurance for the injections. You say that you had a procedure performed on your sinuses and were administered 9 different medications. You say that you are only supposed to pay the outpatient surgery copayment for anything done during the procedure. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered Part B drug.   

You have been asked to pay $433.59, which is 20% of the allowed amount for the injections. The allowed amount is $2,167.93 (20% x $2,167.93 = $433.59). The injections fall within the "Medicare Part B Prescription Drugs" benefit category. You pay a $0 copayment for Medicare-covered surgery but are charged cost sharing if you receive any services or items other than surgery.   

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 the injections provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for immunization services provided to the enrollee on August 9, 2021.  You asked the Plan to pay for the services. You say that this should have been covered. The Plan denied your request. The Plan says this is not a covered benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on August 9, 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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate 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.  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: 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 perform 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the injection procedures you had at an outpatient hospital facility on July 26, 2021, and August 9, 2021.  

You asked the Plan to waive the copayments for the injection procedures. You say that you don't think you should have to pay this because it didn't help and you don't think you need to pay it. 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 $200 copayment for outpatient surgery.     

You have been asked to pay a $200 copayment for the injection procedures. The injection procedures fall within the outpatient surgery benefit category. These copayments apply regardless of whether or not the injections helped you. 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 the injection procedures you had at an outpatient hospital facility on July 26, 2021, and August 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 8 additional home health physical therapy (PT) visits.  You asked the Plan to pre-approve the additional home health PT services. You say that it is felt that additional PT is necessary. The Plan denied your request. The Plan says the enrollee does not require additional services at this time.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional home health PT services. Our reviewer says that the documentation does not support that additional home health PT services are medically reasonable and necessary. Our physician reviewer found the member is a 77-year-old female with a medical history including chronic low back pain from spinal disease. She had a lumbar spine microdiscectomy at L3-L4 on 6/7/21 and has been receiving home health physical therapy since 6/14/21. The documentation indicates the member has been instructed regarding safety measures, fall precautions and a home exercise plan. The most recent therapy documentation indicates the member has improved with therapy and can ambulate up to 140 feet with a rolling walker and does not require hands on assistance for bed mobility or transfers.  The member does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. She has received skilled therapy services and should be independent with a home exercise program. The requested home health services are not medically 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 the additional home health PT services have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional home health physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 5, 2021, to June 11, 2021.  

You asked the Plan to waive the copayment for the inpatient hospital care. You say that there should only be one copayment charged because the enrollee had two sequential hospital stays for the same medical event due to a required hospital transfer. The Plan denied your request. The Plan says this copayment was charged correctly.  The enrollee had two separate admissions.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $450 copayment per day for days 1-4 per admission for inpatient hospital care.     

Records show that the enrollee was an inpatient in the second hospital f0r six days.  The enrollee was charged a $450 copayment per day for each of the first four days, for a total of $1800.  According to the Evidence of Coverage, this copayment applies per admission, even if transferred from a different facility. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 5, 2021, to June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services provided on July 8, 2021, billed with codes 00620 and 99100.  You asked the Plan to pay for the anesthesia services as billed. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says the anesthesia code 00620 is not supported as no surgical procedure that matches this was 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, the CPT Code Manual definition of code 00620 is Anesthesia for procedures on thoracic spine and cord, not otherwise specified.   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 anesthesia services as billed. Our reviewer says that the billed codes are not supported in this case. Our reviewer found no operative report was submitted in support of this code. The anesthesia report alone was reviewed. Per anesthesia report, anesthesia was performed for "SOS Trial" (Stent or Surgery Trial) procedure.  Procedures on thoracic spine and cord is an inappropriate code to report for SOS Trial procedure.    Code 99100 has a status indicator of "B" on the Physician Fee Schedule. This means that payment for this code is always bundled into other services. No separate payment is made for this code.   We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on July 8, 2021, billed with codes 00620 and 99100.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that you need an extension in the SNF because you cannot take care of yourself every day. You say that you can barely walk with a walker, have to wear back and neck braces, and have no one at home who can help you. The Plan denied your request. The Plan says the enrollee no longer requires daily skilled services. The Plan says that the continuation of SNF care is not medically necessary.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee 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 beyond the last covered date. The documentation does not reveal evidence of complex wound care or other skilled nursing SNF need. The enrollee'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 beyond the last covered date  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.