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

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for respiratory distress following a recent Covid-19 infection. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the brief emotional behavioral assessment (36127) and the office visit (99215) rendered by an out-of-network (OON) provider on July 1, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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.  You are 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 brief emotional behavioral assessment (36127) and the office visit (99215) rendered by an out-of-network (OON) provider on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services (36415, 83550, 82728, 83540) provided on October 12, 2021.  You asked the Plan to waive the copayment for the laboratory services. You say that you feel you shouldn't have to pay for these services. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services 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 a 20% coinsurance for out-of-network Outpatient diagnostic tests and therapeutic services and supplies.    You have been asked to pay a 20% coinsurance for laboratory services (allowed is $31.84 x 20% = $6.37). Laboratory services fall within the Outpatient diagnostic tests and therapeutic services and supplies 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 laboratory services (36415, 83550, 82728, 83540) provided on October 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for speech pathology services provided from June 17, 2021, through July 1, 2021.  You asked the Plan to pay for speech pathology services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or the facility.  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 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 speech pathology services provided from June 17, 2021, through July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve L2 lumbar kyphoplasty for the enrollee.  You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says this request does not meet the requirements for approval.  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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found retropulsion into the canal is a contra-indication to the procedure. The request is not medically reasonable or 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve L2 lumbar kyphoplasty for the enrollee.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to waive the copayment for remote cardiac monitoring provided on July 20, 2021.  

You asked the Plan to waive the copayment for remote cardiac monitoring. You say that you have never been charged in the past and disagree with the charges. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for diagnostic tests and procedures.   

The Plan says you must pay a $35.18 copayment for remote cardiac monitoring. Remote cardiac monitoring is considered an outpatient diagnostic test. Based on the Plan contract, you cannot be asked to pay more than a $0 copayment for diagnostic tests. Therefore, we decided that the Plan has to waive the copayment for remote cardiac monitoring provided on July 20, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on October 21, 2021.  You asked the Plan to pay for the dental services. You say that you feel this service should be covered. You say that you did not even use your general cleaning services. You also say that you need help because life is so hard right now. The Plan denied your request. The Plan says limited oral evaluation and periapical x-ray are not listed as covered services.  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.  Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation and periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for selective catheter placement, arterial system; thoracic or brachiocephalic branch (36215) angiography, extremity, bilateral, radiological supervision and interpretation (75710).  You asked the Plan to pay for the surgical procedure. You say that please see the attached highlighted medical records indicating the additional service that warrants separate reimbursement. The Plan denied your request. The Plan says the operative report did not include documentation that of procedure codes 32615-59 and 75710-59 as independent procedures.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    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 surgical procedure Our reviewer says that the records do not support the criteria has been met. Our physician reviewer found in this case, because a complete arteriogram was performed for specific suspicion of an inflow stenosis, and because the catheter was advanced retrograde to the more proximal artery, 75710 and 36215 are reported. The procedure report does not include enough documentation to support CPT 36215 and CPT 75710 to verify correct codes were reported. Procedure report states: "Attention was then turned toward the arterial inflow. Selective catheterization of the brachial artery was performed and an arteriogram obtained. This was done to evaluate for inflow stenosis". There is not enough documentation in this procedure to confirm additional coding.  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 surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay for selective catheter placement, arterial system; thoracic or brachiocephalic branch (36215) angiography, extremity, bilateral, radiological supervision and interpretation (75710).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a participating provider on October 4, 2021.  You asked the Plan to pay for a comprehensive oral evaluation. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for D0150 has already been exhausted.  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 one comprehensive oral evaluation every 36 months.   We looked the file and Medicare rules. Evidence was provided to show that a comprehensive oral evaluation was provided on October 18. 2019. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a participating provider on October 4, 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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.  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. You do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. At your current level of function, you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. You need routine physical therapy (PT) and occupational therapy (OT) in a lower intensity level. While you may benefit from PT, and OT, your rehab needs can be safely met in an alternate and lower intensity setting. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (CPT code 97530) provided to the enrollee on July 15, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  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 service. Our reviewer found the provider reported CPT 97530 therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes for services provided. Documentation submitted was reviewed and does not meet criteria.  The therapy visit documents show a home visit performed by a Certified Occupational Therapist (COTA) on July 15, 2021. For reporting therapy services performed in the home, there is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report. Services documented should not be reported with a CPT code.  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 service have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (CPT code 97530) provided to the enrollee on July 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.  

You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not meet criteria.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing or skilled therapy needs.  You appear to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services for a home visit provided on June 15, 2021.       

You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  

The enrollee ended Medicare Hospice benefits on June 11, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services for a home visit provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction and a contact lens fitting provided on October 26, 2021.  You asked the Plan to pay for an eye refraction and a contact lens fitting. The Plan denied your request. The Plan says the refraction exam and lens fitting are not Medicare covered benefits.  Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only or for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.    We looked at the file and the Medicare rules. Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only or for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction and a contact lens fitting provided on October 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the infusion supplies (A4221, J3285, and K0455) provided on August 13, 2019, through September 11, 2019.  You asked the Plan to pay for the infusion supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include a complete Proof of Delivery.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the infusion supplies (A4221, J3285, and K0455) provided on August 13, 2019, through September 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found your medical condition is reported to be resolved or stable on outpatient medications with no issues that require a physician's evaluation three or more times per week. You will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to his level of weakness, disability and lethargy. Care at the skilled nursing facility level appears to be appropriate in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.