Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve 6 additional home health skilled nursing visits. You say that 6 additional 
home health skilled nursing visits are medically necessary. The Plan denied your request. The Plan says 6 
additional home health skilled nursing visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 6 additional home health skilled nursing 
visits. Our reviewer says that 6 additional home health skilled nursing visits are not medically necessary. Our 
physician reviewer found the records do not show that skilled nursing services are required to effectively 
provide treatment, care, and/or services in order to improve the  enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee is 
medically stable, has no complex wounds, no IV medications or new enteral feedings. The enrollee does not 
require the ongoing skills of a professional nurse therefore the requested additional skilled nursing visits are not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 additional home health skilled nursing visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 6 additional home health skilled nursing visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided March 3, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
for medical necessity. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that the CP must document, in the patient's medical 
record, the date the patient consented or declined consent to consultations, the date of consultation, or, if 
attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. In this case, the record does not document that the CP consulted with 
the patient's attending or primary care physician, or if there was an attempt made to consult them. Based on 
this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided 
March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no documentation that the enrollee requires the intensive rehabilitat ion 
therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears 
to be 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, 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.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307) provided on March 10, 2021 by an outof-
network (OON) provider.

You asked the Plan to pay for OON drug testing. You say that you were not able to obtain authorization. The
Plan denied your request. The Plan says authorization is required for OON services.

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 drug testing (80307) provided on March 10, 2021
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the vitamin D testing provided on March 15, 2021.

You asked the Plan to pay for the vitamin D testing. You say that this testing should be paid. The Plan denied your request. The Plan says that vitamin assays like vitamin D testing are screening and cannot be covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that vitamin testing may be considered reasonable and necessary when certain criteria are met. The rules also say that if an enrollee is known to be deficient, annual testing may be reasonable and necessary. 

In this case, the enrollee has a history of known vitamin D deficiency since 2019, for whom vitamin D supplementation has been ordered. This is annual testing to monitor for effect of the vitamin D supplementation. This is specifically allowed by the LCD criteria. Therefore, we decided that the Plan has to pay for the vitamin D testing provided on March 15, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for vitamin D testing (82306) provided on May 25, 2021.

You asked the Plan to pay for vitamin D testing. You say that this is supported by the records. The Plan denied your request. The Plan says this was performed for screening purposes.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal, vitamin D testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for vitamin D testing (82306) provided on May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found Based on the documentation provided, 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.

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 pre-approve additional home health physical therapy services.

You asked the Plan to pre-approve additional home health physical therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 additional home health physical therapy services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee required supervision and a rollator for walking 300 feet. The enrollee has been instructed in a home exercise program. The documentation does not support that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. The enrollee can transition to an independent home exercise program. 

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 home health physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health physical therapy services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on March 31, 2021, billed with codes
82248, 84446, 82607, 84134, 82746, 86803, and 84425.

You asked the Plan to pay for the lab testing. You say that this was denied for the use of modifier -PO which is
an appropriate modifier. This claim should not be denied for this issue. The Plan denied your request. The Plan
says this was screening testing that is not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must submit information that
corroborates the documentation in the beneficiary's medical documentation and confirms that Medicare
coverage criteria have been met.

In this case, the Plan made several attempts to request medical records from the ordering provider to support
the necessity of this testing. No records were submitted. Without documentation confirming that Medicare
criteria are met, payment cannot be made for this testing. Therefore, we decided that the Plan does not have to
pay for the lab testing provided on March 31, 2021, billed with codes 82248, 84446, 82607, 84134, 82746,
86803, and 84425.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the review has determined 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. The enrollee does not require treatment
by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation
therapy program.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on May 14, 2020 by an out-ofnetwork
(OON) provider.

You asked the Plan to pay for lab test. You say that this testing was medically necessary. The Plan denied your
request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network
with the Plan and authorization was not obtained.

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 laboratory testing provided on May 14, 2020 by an
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast biopsy provided on May 12, 2021.

You asked the Plan to waive the copayment for a breast biopsy. You say that you thought that the charges would be fully covered. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

You received a breast biopsy on May 12, 2021, at an outpatient hospital facility. A breast biopsy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment. 

You have been asked to pay a $275 copayment for a breast biopsy. A breast biopsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 breast biopsy provided on May 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient mental health stay provided by a subacute
Extended Acute Care unit.

You asked the Plan to pre-approve an inpatient mental health stay. You say that the enrollee is not safe to
discharge based on clinical presentation. The Plan denied your request. The Plan says this level of inpatient
psychiatric level of care is not medically necessary.

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 an inpatient mental health stay. Our
reviewer says that based upon the records that were provided for the admission of this patient does not meet the
criteria for continued acute inpatient mental health treatment for the dates in question of August 30, 2021
forward. Our physician reviewer found that the enrollee does not 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 delusions,
auditory or visual hallucinations while being cooperative with treatment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an inpatient mental health stay have not been met. Therefore, we decided that
the Plan does not have to pre-approve an inpatient mental health stay provided by a Subacute Extended Acute
Care unit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on March 27,
2021.
You asked the Plan to waive the copayment for ambulance services. You say that you had a minor nose bleed
and did not want the ambulance services. The Plan denied your request. The Plan says the claims were
processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $350
copayment for ambulance services.
You have been asked to pay a $350 copayment for ambulance services. Ambulance services fall within the
ambulance 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 ambulance services
provided on March 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99213, 20610, J1040) provided on May 26, 2021.

You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were network providers available.

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 services 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 these services. Therefore, we decided that the Plan does not have to pay for anesthesia services (99213, 20610, J1040) provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation
(92014) rendered by the out-of-network (OON) provider on June 10, 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 ophthalmological medical examination and evaluation (92014) rendered by the out-of-network (OON) provider on June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and sleeves (E0673) provided to the enrollee on November 12, 2020.

You asked the Plan to pay for the pneumatic compression device and sleeves. You say that this should be covered by the Plan. The Plan denied your request. The Plan says that payment for this service is the responsibility of the facility or hospital that provided the surgery.

The Plan must follow Medicare rules. The rules state that a Pneumatic Compression Device (PCD) coded as E0675 to treat peripheral arterial disease (PAD) is not eligible for reimbursement 

We looked at the file and Medicare rules. Specifically, this item is not a covered benefit of Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and sleeves (E0673) provided to the enrollee on November 12, 2020.