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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) and subsequent hospital 
care (99233) provided on April 11, 2021. 
 
You asked the Plan to pay for the critical care services and subsequent hospital care. You say that you would 
like these claims reprocessed based on medical necessity. The Plan denied your request. The Plan says the 
medical records do not corroborate the codes 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. The CPT Code Manual definition of code 99233 is 
subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 
these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new 
problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the critical care services and subsequent hospital care. Our 
reviewer says that the medical records do not support the services as billed. Our reviewer found the review 
indicates that the documentation submitted did not support a critical care visit of 30-74 minutes was performed 
on the billed date of service. The documentation does not include the time spent providing this service; 
therefore, the billed Critical Care Evaluation and Management code cannot be verified. In addition, the medical 
records do not support the billed code 99233. The criteria for this specific billed code have not been met. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the critical care services and subsequent hospital care have not been met. 
Therefore, we decided that the Plan does not have to pay for the critical care services (99291) and subsequent 
hospital care (99233) provided on April 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87640, 
87798) provided June 19, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 codes 87486, 87496, 87498, 87541, 87581, 87640, & 87798, are not supported in the medical 
record. Specifically, the place of service on the claim (81, lab) did not match the place of service detailed in the 
records (13, assisted living). Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87486, 
87496, 87498, 87541, 87581, 87640, 87798) provided June 19, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 2, 2021 to March 31, 2021.
You asked the Plan to pay for home health services. 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 as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, we find that the Q code line needs to have the same date of service as the first service date on the claim. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 2, 2021 to March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance charged for durable medical equipment.

You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct. The Plan denied your request. The Plan says this coinsurance was charged based on the Plan contract agreement and the supplies provided.

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 20% coinsurance for durable medical equipment. 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 20% coinsurance charged for durable medical equipment provided April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for supervision of a nursing facility patient (99380) provided on March 27, 2021.
You asked the Plan to pay for supervision of a nursing facility patient. You say that you would like this claim reprocessed based on the records submitted. The Plan denied your request. The Plan says this claim is always bundled into payment for other services not specified and no separate payment is made.
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 99380 is supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more. We find that CPT code 99380 is not supported in the medical record. Specifically, CPT code 99380 has a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 99380. Based on this information, we decided that Medicare rules for coverage of supervision of a nursing facility patient have not been met. Therefore, we decided that the Plan does not have to pay for supervision of a nursing facility patient (99380) provided on March 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged office or other outpatient evaluation and management service(s) coded G2212 provided on May 11, 2021.
You asked the Plan to pay for the prolonged office or other outpatient evaluation and management service(s). 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 supported by the documentation.
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 G2212 is prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to codes 99205, 99215 for office or other outpatient evaluation and management services) (do not report g2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (do not report g2212 for any time unit less than 15 minutes). We find that CPT code G2212 is not supported in the medical record. Specifically, the documentation does not support that Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact was performed. Based on this information, we decided that Medicare rules for coverage of the prolonged office or other outpatient evaluation and management service(s) have not been met. Therefore, we decided that the Plan does not have to pay for the prolonged office or other outpatient evaluation and management service(s) coded G2212 provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation discharge services (99217) provided on June 25, 2021.

You asked the Plan to pay for observation discharge services. You say that you would like this claim reprocessed based on the medical records submitted. The Plan denied your request. The Plan says because a qualifying initial or subsequent observation care service, or another service resulting in an observation stay has not been reported, the discharge service denied appropriately.

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 99217 is observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]).

We find that CPT code 99217 is not supported in the medical record. Specifically, the documentation submitted does not include evidence that a qualifying initial or subsequent observation care service has been rendered or reported. Based on this information, we decided that Medicare rules for coverage of observation discharge services have not been met. Therefore, we decided that the Plan does not have to pay for observation discharge services (99217) provided on June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity device (L8702). 
 
You asked the Plan to pre-approve the powered upper extremity device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says this device is experimental and non-covered. 
 
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 the powered upper extremity device. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found current clinical guidelines designate robotic therapy to have unproven benefit in 
the home environment. In addition, the provided records show that the enrollee has a shoulder subluxation 
which may be a contraindication to use of the requested device. 
 
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 powered upper extremity device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a powered upper extremity device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance for durable medical equipment. 
 
You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct. The 
Plan denied your request. The Plan says this coinsurance is a contractual obligation. 
 
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 20% 
coinsurance for durable medical equipment. 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 20% coinsurance for durable medical 
equipment provided on April 1, 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 you need IRF care. The Plan denied your request. The Plan says the criteria for IRF care 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 the patient was admitted for acute on chronic congestive heart failure. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient 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 inpatient psychiatric care from October 31, 2021, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 31, 2021, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
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 inpatient psychiatric care from October 
31, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of October 31, 2021, forward. Our physician reviewer found you do not 
require inpatient mental health treatment beyond October 31, 2021, as you were not a danger to yourself or 
others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment 
was taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from October 31, 2021, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 31, 
2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (85025) rendered by the out-of-
network (OON) provider on July 21, 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 laboratory service (85025) rendered by the out-of-network (OON) provider on  
July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 
24, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were told you were 
not in observation. You say you are not paying the $20 copayment for being in the emergency room. The Plan 
denied your request. The Plan says you have been asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for each in-person specialist visit, including outpatient clinic visits.  
 
You have been asked to pay a $20 copayment for the specialist office visit. The specialist office visit falls 
within the "Outpatient hospital services" benefit category. The record shows the specialist visit was received 
while you were an outpatient. 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 specialist office visit provided on May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning represented by code 99497 
provided on March 27, 2021. 
 
You asked the Plan to pay for code 99497. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99497. 
 
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 99497 is Advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. Specifically, code 99497 is a time-based 
code. In order to bill code 99497, the documentation must note that the first 30 minutes were face-to-face with 
the patient, family member(s), and/or surrogate for advance care planning. The records do not document this. 
Based on this information, we decided that Medicare rules for coverage of code 99497 have not been met. 
Therefore, we decided that the Plan does not have to pay for the advance care planning represented by code 
99497 provided on March 27, 2021.