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

 We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0426, A0425) provided on June 2, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you do not feel this service was necessary, but you were told it was by hospital staff. You feel you should not be liable for this cost because this care was not your choice. The Plan denied your request. The Plan says the ambulance services were covered as they were medically necessary. This claim was processed correctly, and your copayment was assessed in accordance with your 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 $250 copayment for ambulance services.   You have been asked to pay a $250 copayment for the ambulance services. 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 ambulance transportation services (A0426, A0425) provided on June 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient surgical procedure you had on February 5, 2021.  You asked the Plan to waive the copayment for the outpatient surgery. You say that this procedure was needed as a result of an error in December 2020. 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 copayment each visit for outpatient surgery.   You have been asked to pay a $300 copayment each visit for the outpatient surgery. This copayment applies regardless of the reason for the procedure. 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 outpatient surgical procedure you had on February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the frames (V2020), polycarbonate lenses (V2784), and vision item or service, miscellaneous (V2799) provided August 4, 2021.  You asked the Plan to provide additional payment for the frames, polycarbonate lenses and miscellaneous vision item or service. You say that you don't understand why your claim for eyeglasses was denied. The Plan denied your request. The Plan says that the full vision allowance was applied these claims and a check was sent to you on September 21, 2021. You are responsible for the remaining cost.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $250 allowance.  We looked at the file and the Plan's rules. The Plan provided documentation showing that the full $250 allowance has been applied to your eyeglasses.  Therefore, we decided that the Plan does not have to provide additional payment for the frames (V2020), polycarbonate lenses (V2784), and vision item or service, miscellaneous (V2799) provided August 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).  You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare can only pay for services that are medically necessary and reasonable.  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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical problems are stable.  There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a comprehensive oral evaluation - new or established patient (D0150) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) to be provided by an oral surgeon.  You asked the Plan to pre-approve a comprehensive oral exam and tooth extraction to be performed by an oral surgeon. You say that you need this tooth removed as soon as possible. The Plan denied your request. The Plan says these services are only covered when performed by a participating dentist  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. The Plan covers a comprehensive oral exam and tooth extraction to be performed by an oral surgeon when the services are performed by a participating general dentist.  We looked at the file and Medicare rules. In this case the services are requested to be performed by an oral surgeon. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral exam and tooth extraction to be performed by an oral surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation - new or established patient (D0150) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) to be provided by an oral surgeon.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy (PT) services provided from March 30, 2021, through August 17, 2021.  You asked the Plan to pay for the PT services. You say that it is felt that the PT provided was medically necessary. The Plan denied your request. The Plan says the enrollee did not require the PT services provided during these dates.  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 pay for the PT 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 enrollee had a stroke in July 2020 and has received PT for acquired disability from this stroke. She has gait instability and generalized weakness. In February of 2021, the patient was transitioned to a maintenance program.    The additional outpatient physical therapy services provided from March 30, 2021, to August 31, 2021 were not medically necessary. The additiona  requested therapy was 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 extensive therapy, and her functional level at the time of March 30,2021 was not supported by the records to need ongoing skilled PT. The records do not demonstrate that the unique skills of a professional therapist were required to safely and effectively provide treatment, that the services could have been safely and effectively performed only by a therapist or under the supervision of a therapist during the dates in question. The patient was already independent in a home exercise program. The requested services were not part of a maintenance program needing 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 the PT services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided from March 30, 2021, through August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for wound care supplies provided on July 29, 2021.  You asked the Plan to pay for the wound care supplies. You say that the patient had an approved admission in a nursing home as a resident and is entitled to coverage of these supplies. The Plan denied your request. The Plan says the patient was admitted in a covered inpatient hospital stay at the time these supplies were provided, so no separate payment can be made.  The Plan must follow Medicare rules. Medicare rules say that when a patient is an inpatient in a hospital, no separate payment is made for supplies or other equipment provided because payment for these items is included in the inpatient prospective payment system payment to the facility.  In this case, records show that on the date of service when these supplies were billed, the patient was an inpatient in a hospital. Therefore, we decided that the Plan does not have to pay for wound care supplies provided on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services provided on May 28, 2021, billed with codes 36246-XU and 75716-XU.  You asked the Plan to pay for the services as billed. You say that this should be paid. The Plan denied your request. The Plan says these are not correctly billed as the modifier is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  CPT codes 36246 and 75716 are Column 2 codes in relation to code 37224. This means that they are only payable if the modifier -XU is deemed clinically appropriate.  We asked our coding 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 the services as billed. Our reviewer says that the use of these modifiers is not supported to bypass the edits. Our coding reviewer found CPT 36246 and 75716 have a bundled relationship with CPT 37224 that was performed on May 28, 2021. A modifier is allowed to unbundle these services, providing the medical records justify the use of an acceptable modifier. In this case, the medical records submitted does not include sufficient documentation to append a modifier to CPT 36246 or 75716. Therefore, no additional reimbursement is allowed.  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 services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services provided on May 28, 2021, billed with codes 36246-XU and 75716-XU.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab testing provided on March 10, 2021.  You asked the Plan to pay for the lab testing. You say that this should be approved as this lab offers the testing that ESRD facilities require. The Plan denied your request. The Plan says this is not separately payable.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab testing provided on March 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from October 17, 2020, through October 22, 2020, billed with principal diagnosis code J96.01.  You asked the Plan to pay for the inpatient care as billed. You say that this was billed correctly. The Plan denied your request. The Plan says the billed DRG is not supported due to the incorrect principal diagnosis code.  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.    In this case, you billed the inpatient services provided with principal diagnosis code J96.01, defined as acute respiratory failure with hypoxia. 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 the inpatient care as billed. Our reviewer says that the records do not support the use of J96.01 as the principal diagnosis. Our physician reviewer found the enrollee was admitted with community-acquired pneumonia with chronic obstructive pulmonary disease (COPD) exacerbation. He presented to the hospital with 100% oxygen saturation on room air and later this dropped to 93% on 2 Liters per minute oxygen. Physical exam revealed no work of breathing or respiratory distress during the admission but did reveal tachycardia. Oxygen requirements did not increase during the hospital stay. Pulmonary consultation stated that the patient "may be able to discontinue oxygen therapy". Based on the provided documentation, there was insufficient support made for using the diagnosis of acute respiratory failure with hypoxia considering they only required low dose oxygen to maintain normal oxygenation and was not in significant respiratory distress throughout the hospital stay.    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 the inpatient hospital care provided from October 17, 2020, through October 22, 2020, billed with principal diagnosis code J96.01.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee brace provided on August 20, 2021.  You asked the Plan to pay for the knee brace. You say that this item was medically necessary for the patient and was ordered by his doctor. The Plan denied your request. The Plan says it contacted the provider that you stated on the claim ordered this item for the patient.  This doctor stated definitively that they did NOT request this item for the patient.  The Plan then called the member to get more information about this item.  The member confirmed that your organization called them 'out of the blue' and told her that her doctor said he needed this item.  The member confirmed that his physician had not ever evaluated him for knee pain. This is not permitted. Further, there are no records suggesting that the patient would even meet medical criteria for this brace.  The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.  We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the knee brace have not been met. Therefore, we decided that the Plan does not have to pay for the knee brace provided on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab testing provided on May 12, 2021.  You asked the Plan to pay for the lab testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not separately payable.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab testing provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit (99214) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an office visit. You say that you are currently under the care of this provider and to please consult your medical history to show how important it is to see your doctor once a year. The Plan denied your request. The Plan says you were last seen by the out of network provider on January 13, 2021. The Plan also says that at this point, you can be seen by in-network providers, who are available, because there is no gap nor is their less than 90 days of continuity of care (COC).  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.      The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit (99214) to be provided 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 services rendered on April 26, 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 were not billed correctly.  The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.   We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided December 7, 2020.  You asked the Plan to pay for the non-emergency ambulance services. You say that documentation of the enrollee's condition substantiates the medical necessity for the services. The Plan denied your request. The Plan says a physician's office/clinic/outpatient center is not a covered destination.  Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 the non-emergency ambulance service. Our reviewer says that the non-emergency ambulance transportation provided December 7, 2020, was not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that other means of transport (such as a stretcher van or wheelchair van) were contraindicated for this enrollee on December 7, 2020. The enrollee was noted to have a right lower extremity amputation and weakness of the extremities, but records do not document any abnormalities or unstable vital signs on physical assessment which would necessitate ambulance transport as opposed to transport via a stretcher van or wheelchair van.  There is no documentation that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on December 7, 2020. Based on the medical records provided there is no documentation that the ambulance transport on December 7, 2020 met Medicare criteria for medically reasonable and necessary for the enrollee.   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 non-emergency ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.  You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric hospital bed is medically necessary. The Plan denied your request. The Plan says a total electric hospital bed is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.