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 member's nursing, medical management and rehabilitation needs do
not require an interdisciplinary team approach to delivery of rehabilitation 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for nonsurgical management of a pelvic fracture after a fall. The enrollee's 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 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: 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 feel the IRF admission should be covered. The Plan denied your request. The Plan says the requested IRF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from August 28, 2020, to September 22, 2020.
You asked the Plan to pay for home healthcare. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim was not billed with appropriate coding.
The Plan must follow Medicare rules. Medicare rules say that in addition to reporting a visit line using a G- code, the home health agency must report an additional line item with the same revenue code and date of service, reporting one of the three Q- codes, one unit, and a nominal covered charge. We looked at the file and Medicare rules. The Q- code billed with the first visit reported on the claim was not billed with the same revenue code as the G- code reported for the first visit on this claim. Therefore, this claim
was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of home healthcare have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided from August 28, 2020, to September 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endoscopy with a biopsy (43239) provided on March 8, 2021.
You asked the Plan to waive the copayment for the endoscopy with biopsy. You say that you are unhappy that you have to pay this much for this service. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.
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 $350 copayment for outpatient surgical procedures and services, including, but not limited to, diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.
You have been asked to pay a $190.03 copayment for the endoscopy with biopsy. An endoscopy with biopsy falls within the outpatient surgical procedures and services 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 an endoscopy with a biopsy (43239) provided on March 8, 2021.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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 is receiving appropriate care at the present acute care hospital. 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.
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 enrollee will clearly benefit from acute rehab to
optimize their level of function prior to returning home. The Plan denied your request. The Plan says the
criteria for admission to an IRF are not met. The enrollee would be equally well served 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 the enrollee's 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 this
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99100) provided to the enrollee on
October 14, 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 payment for this code is always bundled into payment for other services not specified, and no
separate payment is made per Medicare.

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 99100 is "Anesthesia for patient of extreme age, younger
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)."

We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status
indicator of "B." This code cannot be paid for separately, as payment for this code is always bundled into
payment for other codes. 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 anesthesia services
(99100) provided to the enrollee on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 8, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 8, 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 would like an IRF admission covered. The Plan denied your request. The Plan says criteria for admission to the IRF setting 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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network physician services.
You asked the Plan to pre-approve out-of-network services. You say that you prefer to see the requested
provider. The Plan denied your request. The Plan says there are providers in network who can render treatment.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out-of-area urgent care and pre-approved care. The provider in this case is not a network provider
with the Plan. The Plan had network providers available who could have provided the items/services at issue in
this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
out-of-network physician services.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for a comprehensive hearing and speech recognition test. We decided that the Plan does not have to reduce the copayment for a comprehensive hearing and speech recognition test to the amount you requested.
You asked the Plan to reduce the copayment for a comprehensive hearing and speech recognition test. You say that you disagree with the high copayment because this was a routine procedure. The Plan says that the claims were processed correctly, and you are being charged the correct amount.
We decided that the Plan has to reduce the copayment for a comprehensive hearing and speech recognition test from $306.63 to $25.
Your contract with the Plan says that you must pay a $25 copayment for diagnostic procedures and tests provided in an outpatient hospital facility. The claims submitted did not indicate that the provider billed for an outpatient hospital facility visit and that they only billed for a comprehensive hearing and speech recognition test. The Plan says that you must pay $306.63 for a comprehensive hearing and speech recognition test. However, you cannot be asked to pay more than a $25 copayment for a diagnostic procedure or test provided at an outpatient hospital facility. Therefore, we decided that the Plan has to reduce the copayment for a comprehensive hearing and speech recognition test from $306.63 to $25.
We also decided that the Plan does not have to reduce the copayment for a comprehensive hearing and speech recognition test to the amount you requested.
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 $25 copayment for a comprehensive hearing and speech recognition test. Therefore, we decided that the Plan does not have to waive the $25 copayment for a comprehensive hearing and speech recognition test.
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 pay for physician services provided from March 2, 2021, to March 9,
2021.
You asked the Plan to pay for out of network services. You say that you believe the Plan should cover these
services. The Plan denied your request. The Plan says you did not have prior authorization for out of network
care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan.
The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to
pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services
provided from March 2, 2021, to March 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214 and 99215), provided on December 24, 2020, to December 26, 2020.
You asked the Plan to pay for the office visits. You say that the services should be covered. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition while on hospice. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the office visit (99214 and 99215), provided on December 24, 2020, to December 26, 2020.
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 this is the appropriate level of care of the enrollee. The Plan denied your request. The Plan says there is no advantage in moving the enrollee from the current location.

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 physician reviewer found that the enrollee was admitted to the current acute care hospital for acute on chronic hypoxic respiratory failure and pneumonia requiring mechanical ventilation. She was treated with antibiotics, fluids, suctioning, bronchodilators, and has initiated ventilator weaning and is tolerating trach collar again according to recent notes. The enrollee appears to be improving and only requires short-term additional acute care services that can safely be received at the current acute care hospital. The enrollee does not require services at the LTACH that are not already available at the current 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an SCS trial is covered when specific criteria are met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. She has had two level hemilaminectomies. She states she can't do physical therapy due to pain. She was seen by a psychologist and cleared for the SCS trial; however, there is no documentation of other multiple medication trials, transcutaneous electrical nerve stimulation (TENS) therapy, or other physical medicine techniques. There is no an adequate trial of conservative therapy; therefore, the SCS trial is not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial.