Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you require IRF care to gain more strength and you
can complete your dialysis at the facility. The Plan denied your request. The Plan says you do not meet the
Medicare criteria for admission to an IRF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and
benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 IRF care is the enrollee's best chance for recovery and return to her prior level of function. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

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

 We decided that the Plan does not have to pay for a home visit (99350, 99354) provided on June 10, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for a home visit. You say that the facility the enrollee was living at requested the home visit from this provider. The Plan denied your request. The Plan says the services did not have 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 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 home visit (99350, 99354) provided on June 10, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on June 3, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that the claim was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.  Therefore, we decided that the Plan does not have to pay for the laboratory work provided on June 3, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting provided from June 29, 2021, to July 3, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you were in the hospital during the dates of service in this case. You say that you could not administer any medication to yourself. You also say that these services should be covered.  The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting provided from June 29, 2021, to July 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intensity modulated radiotherapy (IMRT) plan coded 77301 provided on July 12, 2021.  You asked the Plan to pay for the intensity modulated radiotherapy plan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  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 77301 is intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications.    We find that CPT code 77301 is not supported in the medical record. Specifically, only one plan is needed per course of radiation unless there is significant change in tumor volume or enrollee anatomy is shown. Review of the file shows that this code was previously billed on July 2, 2021. The documentation submitted did not show a change in tumor volume or significant change in patient status that would require a new IMRT plan. Based on this information, we decided that Medicare rules for coverage of the intensity modulated radiotherapy plan have not been met. Therefore, we decided that the Plan does not have to pay for the intensity modulated radiotherapy (IMRT) plan coded 77301 provided on July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency ambulance transport (A0427) and inpatient hospital stay provided from July 9, 2021, to July 15, 2021.  You asked the Plan to waive the copayment for ambulance services and an inpatient hospital stay. You say that you do not feel you should be responsible to pay for the surgical mistake of a contracted doctor. The Plan denied your request. The Plan says the cost-share was applied correctly for the services at issue. The Plan says the medical records and appeal statement indicate the services were performed and the Plan cannot waive the applicable cost-sharing 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). Your contract with the Plan clearly says that you must pay a $240 copayment for Ambulance Services. The Plan contract also clearly says that you must pay a $215 copayment, each day, for the first seven days of Inpatient Hospital Care.  You have been asked to pay a total of $1,100 in copayments for the emergency ambulance transport and inpatient hospital stay, which fall within the Ambulance Services and Inpatient Hospital Care benefit categories, respectively ($215 inpatient copayment ? 4 days = $860 + $240 ambulance copayment = $1,100). This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency ambulance transport (A0427) and inpatient hospital stay provided from July 9, 2021, to July 15, 2021.   Your complaint about a potential surgical mistake 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. The Plan stated in the case narrative sent to Maximus that a quality of care grievance is being handled separately. Please contact the Plan for further information regarding this part of your complaint.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an ambulatory surgery center on August 9, 2021.  You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this should have been a screening colonoscopy with no copayment. 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 $300 for outpatient surgery in an ambulatory surgery center.     You have been asked to pay a $300 for the diagnostic colonoscopy. We looked at the medical records to determine what type of colonoscopy you had.  In order to qualifyt as a screening colonoscopy, the colonoscopy must not be performed to evaluate any existing condition.  The medical records show that this colonoscopy was ordered and performed to evaluate you for abdominal pain in the left lower quadrant.  Because this procedure was performed to evaluate a specific condition or symptom, it is considered a diagnostic procedure for which the surgical copayment applies. 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 diagnostic colonoscopy you had at an ambulatory surgery center on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on July 16, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on July 16, 2021.   Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided on November 20, 2020.  You asked the Plan to pay for the evaluation and management service. You say that the claim was resubmitted with modifier "GV". You also say that the claim should be paid. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.  The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided on November 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (80061, 80053, 84439, 84443) provided on July 20, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that the provider is an independent laboratory and does not receive any patient information until after services are rendered. You also say the patient was seen by an in-network physician with no control over the laboratory used and should not be penalized by having this claim processed as out-of-network. The Plan denied your request. The Plan says the services were not referred by a network provider or rendered in a participating facility. The Plan also says 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 record shows that the referring provider was also not in-network. 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 services (80061, 80053, 84439, 84443) provided on July 20, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the coronavirus testing coded U0004 provided on July 13, 2021.  You asked the Plan to pay for the coronavirus testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.    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, we have confirmed that code U0004 for the coronavirus testing is a column II code to column I code U0003. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the coronavirus testing coded U0004 provided on July 13, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for computed tomography guidance for placement of radiation therapy fields (77014) provided on June 14 to June 18, 2021.  You asked the Plan to pay for computed tomography guidance procedures. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says that procedure code code 77014 is a part of another CPT code and not to be billed separately.  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 Plan has not forwarded any evidence that another procedure was billed or paid. There is no evidence that the billed service is included in another service that was rendered. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for computed tomography guidance for placement of radiation therapy fields (77014) provided on June 14 to June 18, 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: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the copayment for post-cataract glasses provided on August 27, 2021.  You asked the Plan to waive the copayment for post-cataract glasses. You say that the Plan's Evidence of Coverage states no cost you for post-cataract glasses. The Plan denied your request. The Plan says that the correct cost-sharing was applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for eyewear post-cataract surgery.   The Plan says you must pay a $357.60 cost-sharing amount for post-cataract glasses. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for post-cataract glasses. Therefore, we decided that the Plan has to waive the copayment for post-cataract glasses provided on August 27, 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: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency transport (A0427), and ground mileage (A0425) provided on January 5, 2021.You asked the Plan to pay for the ambulance services. You say that the enrollee was not on hospice at the time the transport was provided. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency transport (A0427), and ground mileage (A0425) provided on January 5, 2021.