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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the requested service is not medically necessary, and therefore not coverable.

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 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 was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT code 99233) and initial hospital care (CPT code 99223) provided to the enrollee from January 31, 2021, through February 16, 2021.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the records did not support the services provided on January 31, 2021, February 1, 2021, February 5, 2021, and February 9, 2021, through February 11, 2021.

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 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 services. Our reviewer found per the documentation, the records did not support the services provided on January 31, 2021, February 1, 2021, February 5, 2021, and February 9, 2021 through February 11, 2021 by the provider. Providers are responsible for billing appropriately. You can find these guidelines in the Medicare Claims Processing Manual Chapter 12 Section 30.6.9 - Payment for Inpatient Hospital Visits. There was no medical decision making of high complexity. The review has determined that the records did not support the services provided on January 31, 2021, February 1, 2021, February 5, 2021, and February 9, 2021, through February 11, 2021.

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 have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (CPT code 99233) and initial hospital care (CPT code 99223) provided to the enrollee from January 31, 2021, through February 16, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital observation (CPT code G0378) provided to the
enrollee on January 4, 2021.
You asked the Plan to pay for the hospital observation. You say that the claim should be paid. The Plan denied
your request. The Plan says the services are not supported by the records. The Plan states that medical records
are still needed to support the services provided on date of service January 4, 2021, to include observation
order and time to support the billed hours of observation for CPT codes.
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 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 hospital observation. Our reviewer found based on the
limited notes, some illegible or incomplete, there was insufficient support made for observation status in the
hospital. Vitals were not documented as unstable, and there was no report of the enrollee not tolerating PO
medications. Therefore, this request for observation care will be considered not medically necessary based on
the provided documentation.
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 hospital observation have not been met. Therefore, we decided that the Plan
does not have to pay for the hospital observation (CPT code G0378) provided to the enrollee on January 4,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 8, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 the lab services provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on April 19, 2021.

You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is 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 71045 has a bundled relationship with code 74022, which was previously billed and paid, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (99243) provided on January 19, 2021.

You asked the Plan to pay for the services. You say that you have no control over the coding. The Plan denied your request. The Plan says that this is not a covered service.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were provided the services by a contract provider. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the services (99243) provided on January 19, 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 waive the deductible for the office visit and lab services you received on February 2, 2021, and the chest x-ray you had on March 9, 2021.

You asked the Plan to waive the deductible for the office visit, lab services, and x-ray. You say that you do not believe there is a deductible with your plan. The Plan denied your request. The Plan says you were charged the deductible correctly.

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 there is a $198 deductible which applies to lab services, x-rays, and primary care services. 

The lab services, x-rays, and primary care services you received are all services to which the deductible applies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible which applies to lab services, x-rays, and primary care services. This cost sharing is a contractual obligation that had not been met at the time these services were received. Therefore, we decided that the Plan does not have to waive the deductible for the office visit and lab services you received on February 2, 2021, and the chest x-ray you had on March 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the chemotherapy services provided on March 8, 2021.

You asked the Plan to waive the cost share for the services provided. You say that the enrollee has never paid such a large amount for one treatment. The Plan denied your request. The Plan says there is a coinsurance for the services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. 

The enrollee has been asked to pay a 20% coinsurance for the services provided. The services fall within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan.

This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the chemotherapy services provided on March 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on April 23, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy (45378). You say that you were never given any information on a $250 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 $250 copayment for Outpatient Services. You have been asked to pay a $250 copayment for the diagnostic colonoscopy (45378). The diagnostic colonoscopy (45378) falls within the Outpatient 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 the diagnostic colonoscopy provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on April 6, 2021, and May 7, 2021.
You asked the Plan to pay for the services provided. You say that your appointments are the same as in the past. The Plan denied your request. The Plan says the services are non-Medicare covered exams and adjustments.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The file shows that you received an office visit on April 6, 2021, and May 7, 2021. We looked at the file and the rules. Services other than manual manipulation, when provided by a chiropractor, are not a covered benefit. You also received manual manipulation.
The records do not show that the services were billed with an appropriate modifier. Based on this information,
the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay
for the chiropractic services provided on April 6, 2021, and May 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage, per statute mile (A0425) provided January 28, 2021, February 3, 2021, and March 11, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you feel the cost share is too high. The Plan denied your request. The Plan says the copayment was applied 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 $250 copayment for each one-way Medicare-covered ground ambulance trip. You have been asked to pay a total of $750 ($250 copayment x 3 transports=$750) for the ambulance services. The 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 the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage, per statute mile (A0425) provided January 28, 2021, February 3, 2021, and March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2377, E1007, E1012).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the advanced controller is not medically necessary, as it controls the two items that were not approved.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee is unable to perform a functional weight shift as the enrollee is able to perform stand pivot transfers. The enrollee does not utilize intermittent catheterization for bladder management, and the physician documentation does not reveal that he needs a power seating system to manage increased tone or spasticity. The documentation does not support that it is medically necessary to control the requested power options through the joystick (drive interface). The enrollee's functional ability should be sufficient to control any power options through their own switches. The documentation does not reveal that tilt and recline are medically necessary. The documentation does not reveal evidence of significant edema in the lower extremities or a leg knee brace or cast or an inability to flex the knee ninety degrees. The requested power tilt and recline (R1007), K0040 (center mount elevating leg rests) and E1012 exceed the enrollee's medical need are 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2377, E1007, E1012).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 4, 2021.
You asked the Plan to pay for the services provided. You say that you did not need to be transported. The Plan
denied your request. The Plan says no ambulance transport was provided.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services. Per authority granted under the American Rescue
Plan Act of 2021, the Centers for Medicare and Medicaid Service (CMS) has waived the requirements that an
ambulance service must include transport to allow for treatment in place when transportation was not provided
based on community-wide emergency medical service (EMS) protocols. However, this requires that the
ambulance provider submit a claim for payment under this waiver. You may wish to contact the ambulance
provider in this case to request that a new claim be submitted for payment. Therefore, we decided that the Plan
does not have to pay for the ambulance services provided on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair with tilt in space and accessories.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says a SNF is not considered home.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair with tilt in space and accessories
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network on February 23, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 services 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 the services provided by an out-of-network on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 18, 2021, by an OON
provider.

You asked the Plan to pay for the office visit. You say that the enrollee failed to inform you of their new
insurance. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 file shows the enrollee was seen for a radiation oncology re-evaluation. The 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 services 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
the office visit provided on January 18, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the annual wellness visit provided on
May 7, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 no coinsurance, copayment, or deductible for an in-network annual wellness visit. The applicable cost-sharing will apply to any non-preventive services you receive during this visit.
Enrollees must pay a $10 copayment for primary care office visits. You have been asked to pay a $10 copayment for the annual wellness visit provided. A cost share is applicable as the record indicates that you received a follow up for chronic conditions during this visit. The Plan contract indicates that there will be a cost share applied to an annual wellness visit if non-preventive services are received during this visit. 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 annual wellness visit provided on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on March 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that the services were needed for the enrollee's care. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 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 services 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 the physician services provided on March 17, 2021 by an out-of-network (OON) provider.