Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit with a gastroenterologist you had on June 14, 2021.

You asked the Plan to waive the copayment for the gastroenterology telehealth visit. You say that you should not have to pay this copayment. You stated that you called the office to see if the surgeon was still doing surgery. You stated that when you spoke to the surgeon, you were immediately asked medical questions that you were not prepared for. You stated that had you known you would have had to pay a copayment to talk to them, you would have gone into the office in person. 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 $45 copayment for telehealth visits and consultations with a specialist.

You have been asked to pay a $45 copayment for the gastroenterology telehealth visit. This copayment applies regardless of the reason for the telehealth 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 telehealth visit with a gastroenterologist you had on June 14, 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 records provided support the need for IRF care. The Plan denied your request. The Plan says the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. The Plan says that the criteria for coverage have not been met. The Plan says that the enrollee's needs can be met 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 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. The enrollee was admitted for weakness, hypotension, and hypokalemia after a recent coronavirus infection. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 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 a 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance
transportation (A0428) provided on March 25, 2021.

You asked the Plan to pay for the ground mileage and non-emergency ambulance transportation. You say that
these services should be covered. The Plan denied your request. The Plan says ambulance transport to or from
an outpatient office or facility 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 ground mileage and non-emergency
ambulance transportation. Our reviewer says that the non-emergency ambulance transportation was not
medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee did not require
the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe
transport. Our reviewer found that transportation could have been provided by other means (stretcher van,
wheelchair van) without endangering the enrollee's condition. Our physician reviewer also found that a prudent
layperson would not believe that immediate medical attention was required for someone attending scheduled
medical appointments and/or stable enough to be discharged from scheduled medical appointments.

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 ground mileage and non-emergency ambulance transportation have not been
met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency
ambulance transportation (A0428) provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional True Metrix glucose test strips.
You asked the Plan to pre-approve additional glucose test strips. You say that these services are medically necessary. The Plan denied your request. The Plan says that the recent attempted fill is rejecting because it will result in a quantity greater than allowed in a 30 day time frame.
The Plan follows Medicare rules. Medicare rules say that more than 300 test strips and more than 300 lancets every 3 months are covered if LCD 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 additional glucose test strips. Our reviewer says that additional glucose test strips are not medically reasonable and necessary. There is no explanation as to why you need to check your blood glucose five times per day. You are taking daily lantus and truclity has been added, but it is unclear why you need to check five times per day. Our physician reviewer found that your condition does not meet Medicare criteria for additional glucose test strips. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional glucose test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve additional True Metrix glucose test strips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information provided does not indicate a need for skilled nursing or skilled therapy.

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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Venofer.

You asked the Plan to pre-approve Venofer. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for Venofer until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pre-approve Venofer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultraviolet blood irradiation, Vitamin C IV 50 grams and Prolotherapy provided on February 18, 2021, through April 8, 2021.
You asked the Plan to pay for the ultraviolet blood irradiation, Vitamin C IV 50 grams and Prolotherapy. You say that you would like reconsideration because your condition is complicated and a burden financially. The Plan denied your request. The Plan says these services are not a Medicare covered benefit.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultraviolet blood irradiation, Vitamin C IV 50 grams and Prolotherapy have not been met. Specifically, the documentation submitted does not include any medical records. There is insufficient information to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the ultraviolet blood irradiation, Vitamin C IV 50 grams and Prolotherapy provided on February 18, 2021, through April 8, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the inpatient care provided from July 22, 2020, to July 28, 2020.
You asked the Plan to pay an additional amount for the inpatient care. You say that the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code J69.0 was validated from a clinical and coding perspective. The Plan denied your request. The Plan says the file does not support the billing of ICD-10-CM J69.0, pnemonitis due to inhalation of food and vomit.
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 ICD-10-CM code, J69.0, pnemonitis due to inhalation of food and vomit. 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 an additional amount for the inpatient care. Our reviewer says that the billing of pneumonitis due to inhalation of food and vomit, ICD-10-CM code J69.0 is not supported. Our physician reviewer found the provided documentation indicates "probable aspiration" in Pulmonology consult notes. The reviewer found that in other provider documentation it was unclear and/or inconsistent regarding this condition. Therefore, the reviewer found that the records did not support the billing of ICD-10-CM code, J69.0, pnemonitis due to inhalation of food and vomit. 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 an additional amount for the inpatient care provided from July 22, 2020, to July 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from March 31, 2021, through April 30, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that this code was established to report additional practice expenses incurred during a public health emergency including supplies and additional clinical staff time. You say that the claims should be reprocessed. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.
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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from March 31, 2021, through April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth individual mental health visit
provided on February 3, 2021.

You asked the Plan to waive the copayment for the telehealth individual mental health visit. You say that you
should not be responsible for the copayment. The Plan denied your request. The Plan says you have been asked
to pay 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 $35
copayment for each Medicare-covered office visit for individual mental health session.

You have been asked to pay a $35 copayment for the telehealth individual mental health visit. The telehealth
individual mental health visit falls within the "Physician/Practitioner services, including doctor's office visits"
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 a telehealth individual mental
health visit provided on February 3, 2021.
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 the clinical documentation provided supports the need for SNF care. The Plan denied your request. The Plan says the requested 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 have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. Skilled therapy to improve strength, improve endurance and teach adaptive strategies is medically necessary and reasonable. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. 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.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided on February 29, 2020, through March 4, 2020 at the Diagnosis Related Group (DRG) 872 payment level.

You asked the Plan to pay for the inpatient hospital services at the DRG 872 payment level.. You say that you would like reconsideration because the medical records support the DRG billed. The Plan denied your request. The Plan says that a clinical review of the appeal letter and the documents submitted did not validate A41.9 as the principal diagnosis code for this admission.

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. Specifically, the record indicates that the Plan reviewed medical records. The Plan has not forwarded any clinical documentation so we are unable to determine if criteria for billing DRG 872 have been met. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for inpatient hospital services provided on February 29, 2020, through March 4, 2020 at the Diagnosis Related Group (DRG) 872 payment level.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns (D2740 x2) and core buildup, including any
pins when required (D2950) provided on April 21, 2021, and June 2, 2021.

You asked the Plan to pay for the crowns and core buildup. You say that you were advised by your insurance
agent that these dental services would be covered when you purchased this plan. You also say that your
provider's office confirmed prior to rendering these services that the crowns would be covered. The Plan denied
your request. The Plan says these services are not included on your plan benefit schedule and are not covered
services. The Plan also says that during the call with your provider, they were advised that these services were
non-covered benefits.

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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two
crowns (D2740 x2) and core buildup, including any pins when required (D2950) provided on April 21, 2021,
and June 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for acute inpatient hospital care provided on
April 30 to May 3, 2021.

You asked the Plan to waive the copayment for acute inpatient hospital care. You say that you should not be
responsible because you were hospitalized due to the Coronavirus vaccine. The Plan denied your request. The
Plan says the correct copayment 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 $403
copayment for each day of days 1 to 5 of inpatient hospital care.

You have been asked to pay $806, or a $403 copayment for each day of a 2-day stay for acute inpatient hospital
care. 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 acute inpatient hospital care provided on April 30 to
May 3, 2021.