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

We decided that the Plan does not have to waive the $135 copayment charged for imaging services provided on
December 14, 2020.
You asked the Plan to waive this copayment. You say that you did not realize the cost share had changed from
coinsurance to a copayment. The Plan denied your request. The Plan says this cost share is clearly outlined in
the Plan 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). The enrollee's contract with the Plan clearly says that enrollees
must pay $135 copayment for imaging services. You have been asked to pay the correct amount based on the
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the
Plan. Therefore, we decided that the Plan does not have to waive the $135 copayment charged for imaging
services provided on December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0673 and E0675) provided on March 17, 2021.
You asked the Plan to pay for the pneumatic compression device. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment.
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0673 and E0675) provided on March 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are 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 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 SNF care. 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. The enrollee's high 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 enrollee 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 enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on August 23, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing (81479) provided on February 28, 2021.
You asked the Plan to pay for testing. You say that this testing is covered by Medicare. The Plan denied your request. The Plan says there is not sufficient documentation from the ordering physician to support this was necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules say 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. No records from the ordering provider have been submitted. Without this information, medical necessity cannot be verified. Based on this information, we decided that Medicare rules for coverage of testing have not been met. Therefore, we decided that the Plan does not have to pay for testing (81479) provided on February 28, 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 medical records provided support the need for
care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not
been met. The Plan says that the enrollee's needs can be met at an alternate 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 sepsis and congestive heart failure. 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 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a transthoracic echocardiography.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says that routine re-evaluation of patients with heart failure without any change in clinical
status is not considered medically necessary.
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically
necessary.
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 considered medically reasonable and necessary in this case. Our physician reviewer
found you have a history of congestive heart failure, and it was documented that you have edema in both legs,
and that your weight is increasing. The guidelines state that there is increasing data to support the prognostic
value of diastolic function parameters in patients with systolic dysfunction. When the etiology is in doubt,
echocardiography can document or rule out the common cardiac causes of pulmonary congestion: left-sided
valvular disease, depressed systolic or diastolic function, and cardiomyopathy. In this regard, echocardiography
is the preferred initial diagnostic test when the history, physical examination, and routine laboratory tests
suggest (or cannot eliminate) cardiac disease.
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 been met. Therefore, we decided that the Plan has to preapprove
a transthoracic echocardiography.
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 you need therapy in order to treat your condition. You say that you are lingering at the hospital without a medical need for that level of care and need to move on to therapy. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can receive the care needed in another setting.

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 anemia and congestive heart failure. 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 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from February
10, 2021, to March 11, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. You say that a corrected
claim was submitted. The Plan denied your request. The Plan says the claim denied as the value codes billed
for Home Health services is invalid. A corrected claim is still needed for reprocessing.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due
to an issue with a missing or incorrect code. Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from
February 10, 2021, to March 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay between April 10, 2021, and April 20, 2021.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that the enrollee was transferred from another hospital for better care, and you feel the copayment should be assessed as a continuing inpatient stay. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $335 copayment for each day, days 1 to 5 for Medicare-covered hospital care. The cost-sharing applies each time the enrollee is admitted to the hospital. The enrollee has been asked to pay a total of $1,675 ($335 copayment x 5 days =$1,675) for the inpatient hospital stay. This stay falls within the Inpatient hospital care benefit category. 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 reduce the copayment for the inpatient hospital stay between April 10, 2021, and April 20, 2021.
Your complaint about the Plan's policy to apply cost-sharing separately to each inpatient admission is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 a stay at this level of care is necessary to better the enrollee's condition. The Plan denied your request. The Plan says the clinical criteria for the requested service have not been met.
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 daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required; occupational therapy recommends therapy three times per week; physical therapy recommends treatment four to five times per week. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services
rendered on March 26, 2021.
You asked the Plan to waive the copayment for these services. You say that you do not want to pay for two ER
services. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an $85
copayment for each visit to an emergency room.
Review of the file shows that you received ER services on March 26, 2021. You have been asked to pay an $85
copayment for these services. These services fall within the visit to an emergency room 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 emergency room (ER) services rendered on March 26,
2021.
Your complaint about the provider is not a valid appeal for medical coverage. This part of your complaint is a
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types
of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology procedure (CPT code(s): 81403 and
G0452) provided to the enrollee on February 11, 2021.

You asked the Plan to pay for the laboratory services. You say that the services billed are supported. The Plan
denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code(s): 81403 and G0452 is not supported in the medical record. Specifically, the submitted
documentation did not contain a signed physician order. In addition, there are no authenticated medical records
(e.g., a progress note) from the ordering provider documenting the treating physician had intended the clinical
diagnostic test be performed. Based on this information, we decided that Medicare rules for coverage of the
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the
molecular pathology procedure (CPT code(s): 81403 and G0452) provided to the enrollee on February 11,
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services from September 21, 2021,
forward.
You asked the Plan to pre-approve continued inpatient psychiatric services. You say that you would like
continued coverage for the inpatient psychiatric stay. The Plan denied your request. The Plan says services
requested were not authorized as the enrollee's medical condition is stable, and her care can be safely managed
at a lower level of care such as an assisted living facility.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve continuing inpatient psychiatric
services. Our reviewer says that the continued inpatient psychiatric services from September 21, 2021, forward
are not medically necessary. Our physician reviewer found that this enrollee did not appear to require inpatient
mental health treatment beyond the date in question as she was not a danger to herself or others and did not
have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active
treatment was taking place beyond the date in question. It did not appear that the services were reasonably
expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. This
enrollee was treated under an individualized treatment plan found in the record. It did appear that the records
were supervised and evaluated by a physician. Based upon review the records provided for the admission of
this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in
question of September 21, 2021, forward as this enrollee was not shown to be a danger to herself or others. She
was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not
showing any threats to safety as the enrollee awaited guardianship.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuing inpatient psychiatric services have not been met. Therefore, we
decided that the Plan does not have to pre-approve inpatient psychiatric services from September 21, 2021,
forward
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve internal bleaching (D9974) for tooth #'s 7 and 8.
You asked the Plan to pre-approve the internal bleaching (D9974). You say that it is important that are your teeth are even in color. The Plan denied your request. The Plan says the service is not a covered benefit.
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 pre-approve internal bleaching (D9974) for tooth #'s 7 and 8.