Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits
You asked the Plan to pre-approve the additional PT visits. You say that you are requesting a standard appeal.
The enrollee reports that she is doing better and that she can tell that the pain is progressing. The Plan denied
your request. The Plan says additional PT visits are not medically necessary and the enrollee did not meet the
Medicare criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 PT visits. Our reviewer
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the
enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as
specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this
condition and it does not appear that the enrollee requires the ongoing unique skills of a professional therapist
to safely and effectively provide treatment, or that the services can be safely and effectively performed only by
a therapist or under the supervision of a therapist. The enrollee has been compliant in an independent exercise
program. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish,
design and/or deliver a program to maintain the patient's current condition or to prevent or slow further
deterioration.
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 PT visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional physical therapy (PT) visits.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on August 23, 2021.  You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria were not met.  Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. 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 this transport. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found in this case; the record indicates that the enrollee was transported from acute care to skilled nursing facility.  The record indicates that the enrollee is a fall risk and has lumbar spine disease. The record indicates that the enrollee was transported via stretcher.  The record does not indicate that the patient's clinical condition is such that other methods of transport, such as stretcher van, are contraindicated. The elements of the coverage criteria are not satisfied.     We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transport provided to the enrollee on August 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health services for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation submitted indicates that this request is custodial in nature.  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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there are no documented skilled nursing needs or skilled therapy needs. As such, the requested ongoing home health services are not shown to be medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services for the enrollee.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for injection services provided to the enrollee on July 8, 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 this is a packaged service.  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 J1885 is "Injection, ketorolac tromethamine, per 15 mg."  We find that CPT code J1885 is not supported in the medical record. Specifically, this code has a status indicator of "I" which means that payment is packaged into payment for other services, including outliers.          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 injection services provided to the enrollee on July 8, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve a left hip intra-articular injection under fluoroscopy for the enrollee.  You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that the office note received did not report information regarding the previous injection.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 injection. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the imaging shows severe osteoarthritis of the hip. The progress notes do not detail prior intra-articular hip injection. The request is for fluoroscopic intra-articular hip injection. The request is medically reasonable and 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 injection have been met. Therefore, we decided that the Plan has to pre-approve a left hip intra-articular injection under fluoroscopy for the enrollee.   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 problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on September 13, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you contacted the doctor to determine the cause of numbness in your lower lip and the shooting pains that were occurring in your brain. You also say that the doctor determined that you had an infection from a tooth and treatment was provided. The Plan denied your request. The Plan says problem focused limited oral evaluation is not a covered expense under your dental plan. The Plan also says that your benefits for the first intraoral periapical x-ray have been satisfied and the frequency limitation has been exceeded.  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, problem focused limited oral evaluation (D0140) is not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on August 13, 2021 and your intraoral x-rays benefit had been exhausted.  Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286), partial ostectomy/sequestrectomy for removal of non-vital bone (D7550), and complete series of intraoral x-rays (D0210) provided from January 20, 2021, to June 8, 2021.    You asked the Plan to pay for the incisional biopsy of oral tissue, partial ostectomy/sequestrectomy, and complete series of intraoral x-rays. You say that the surgery was necessary to eliminate the major health issue which is why you are appealing the Plan's decision of no reimbursement. You also say that since surgery is covered under your plan and was needed to remove a major health issue, these services should be covered. The Plan denied your request. The Plan says the incisional biopsy of oral tissue and partial ostectomy/sequestrectomy are not covered expenses under your dental plan. The Plan also says that your benefits for the complete series of intraoral x-rays have been satisfied and the frequency limitation has been exceeded.  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 incisional biopsy of oral tissue (D7286) and partial ostectomy/sequestrectomy for removal of non-vital bone (D7550) are not among those covered under this benefit. The Plan contract says that full mouth or panoramic x-rays share a frequency limitation of one procedure code every five years. The record shows that you received a panoramic x-ray on November 26, 2018 and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286), partial ostectomy/sequestrectomy for removal of non-vital bone (D7550), and complete series of intraoral x-rays (D0210) provided from January 20, 2021, to June 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient care provided to the enrollee on October 26, 2020, to October 28, 2020.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met.   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.    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 these services. Our reviewer says that Medicare billing criteria are not met. Our physician reviewer found the documentation for diagnosis and treatment of Sepsis is not consistent throughout this hospital stay and is only documented as "presumed" in discharge summary.  Therefore, documentation does not support A41.9 as the primary diagnosis.   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 inpatient care provided to the enrollee on October 26, 2020, to October 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says alternate settings can be requested.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR, HHS, AL, LTC). 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for abdominal paracentesis provided on
September 17, 2020.
You asked the Plan to waive the coinsurance for abdominal paracentesis. You say that the enrollee was quoted
a $50 copayment and you feel that the charges are too high. The Plan denied your request. The Plan says the
claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees
must pay 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities
and ambulatory surgical centers.
The enrollee received abdominal paracentesis on September 17, 2020. The total allowed amount is $864.90 and
20% of that is $172.98.
The enrollee has been asked to pay the total coinsurance amount of $172.98 for abdominal paracentesis.
Abdominal paracentesis falls within the outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers 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 waive the
coinsurance for abdominal paracentesis provided on September 17, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve The Wireless Motility Capsule (SmartPill, WMC) for the enrollee.  You asked the Plan to pre-approve this diagnostic service. You say that this service is medically necessary. The Plan denied your request. The Plan says medical necessity has not been established.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 this diagnostic service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Wireless Motility Capsule (Smart Pill, WMC) is FDA approved for evaluation of gastric emptying in gastroparesis, colonic transit in constipation and evaluation of generalized dysmotility. The device is recognized for assessment of gut dysmotilities by both the American Neurogastroenterology and Motility Society as well as by the American Gastroenterology Association. However, WMC has not been widely accepted as standard of care in clinical practice outside of tertiary care specialty centers and is not more readily available than gastric motility or colon transit testing.  Therefore, it would not be covered by Medicare 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 this diagnostic service have not been met. Therefore, we decided that the Plan does not have to pre-approve The Wireless Motility Capsule (Smart Pill, WMC) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for specialist office visits provided from March 20, 2020, to November 9, 2020.  You asked the Plan to waive the copayments for the specialist office visits. You say that you feel that the Plan should cover the copayments due to the coronavirus waivers in place at the time. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for each specialist visit.   The record shows you had two visits with the specialist. Therefore, you have been asked to pay a $25 copayment for each of the specialist office visits, for a total of $50.  Specialist office visits fall 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 copayments for specialist office visits provided from March 20, 2020, to November 9, 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 medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care; does not require transfer to LTACH.  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 more stable now but requires additional short-term acute care services including oxygen weaning that can be safely completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed.  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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for physical therapy for the enrollee.  You asked the Plan to provide coverage for these services. You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 provide coverage for these services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition.  Our physician reviewer found the additional 10 visits of requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The patient has been approved for ample therapy to be instructed in and competent in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.  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 provide coverage for physical therapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist office visit (99214) provided on July 23, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a specialist office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is not a participating provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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 requested 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 a specialist office visit (99214) provided on July 23, 2021, by an out-of-network (OON) provider.