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 clinical information provided supports the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive care in another setting.  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 gastrointestinal bleeding, hemorrhagic shock and acute kidney injury. The enrollee's 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 patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care, provided on June 18, 2021, through July 14, 2021.  You asked the Plan to waive the copayment for the SNF care. You say that the cost share would present a great hardship for you. The Plan denied your request. The Plan says the cost share 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 $20 per a day for each day 21-100; days 1-20 are fully covered for skilled nursing facility (SNF) care.   You have been asked to pay $20 per a day for each day 21-100 for the SNF care. This item falls within the skilled nursing facility (SNF) care 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 skilled nursing facility (SNF) care, provided on June 18, 2021, through July 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the telehealth originating site fee billed by a skilled nursing facility (SNF) from June 15, 2021, through June 21, 2021, billed with code Q3014.  You asked the Plan to pay for the SNF originating site fee. You say that this is paid separately from other Part A services and does not require a prospective payment system code. The Plan denied your request. The Plan says this was not billed appropriately.  The Plan must follow Medicare rules. Medicare rules say that for a SNF to be paid for a telehealth originating site fee, TOB 22X or 23X must be used.      This claim was billed with TOB 213, which is not appropriate for this service. Therefore, we decided that the Plan does not have to pay for the telehealth originating site fee billed by a skilled nursing facility (SNF) from June 15, 2021, through June 21, 2021, billed with code Q3014.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a TDAP vaccine provided on August 25, 2021.  You asked the Plan to pay for this vaccine. You say that your physician said this vaccine was necessary. The Plan denied your request. The Plan says this vaccine must be submitted under your Medicare Part D carrier.  The Plan is correct. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this vaccine under Medicare Part B. The Plan follows the same rules. The records do not show that you were injured or directly exposed to any illness related to this vaccine under Medicare Part B. This vaccine was given as a preventative measure. Therefore, we decided that the Plan does not have to pay for a TDAP vaccine provided on August 25, 2021. Benefits for this vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on
July 6, 2021, through July 8, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the cost share is incorrect. The Plan denied your request. The Plan says the cost share 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 $325 copay per admission for inpatient hospital care.
You have been asked to pay a $325 copay per admission for the inpatient hospital care. This service falls within the inpatient hospital care 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 inpatient hospital care provided on July 6, 2021, through July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections.
You asked the Plan to pre-approve facet injections. You say that the enrollee is eagerly anticipating the requested procedure and further delay or denial subjects him to undue pain and suffering. The Plan denied your request. The Plan says the requested injection services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are covered when medically necessary and for certain clinical indications. 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 facet injections. Our reviewer says that
the criteria for coverage have not been met and the requested injections are not considered medically necessary. Our physician reviewer found the documentation does not support that the previous therapeutic facet joint procedures at the same anatomic site resulted in at least consistent 50% pain relief for at least three months from the prior therapeutic procedure or at least 50% consistent improvement in the ability to perform previously painful movements and activities of daily living (ADLs) as compared to baseline measurement using the same scale. There is also no documentation of why the enrollee is not a candidate for radiofrequency ablation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for holistic energy healing received from January 11, 2021 to March 23, 2021.
You asked the Plan to pay for the services. You say that this helped best for your psychotherapy, and was more effective than other treatment. The Plan denied your request. The Plan says there is no documentation to support this reimbursement request.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for holistic energy healing received from January 11, 2021 to March 23, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (procedure code 01996) provided to the enrollee on June 15, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the code was billed without the required anesthesia modifier.
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 01996 is "Daily hospital management of epidural or subarachnoid continuous drug administration." 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 says that the services at issue in this case were not supported by the medical records. Our reviewer found that in this case, a modifier would be required. Providers and suppliers shall report the HCPCS/CPT code that describes the procedure performed to the greatest specificity possible.
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 anesthesia services (procedure code 01996) provided to the enrollee on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for needle electromyography, (List separately in addition to code for primary procedure) (95886) provided July 13, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you do not agree with the $150 and feels that the copay should only be $30 for the specialist visit. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $150 copayment for Medicare covered diagnostic procedures and tests. You have been asked to pay $150 copayment for the diagnostic service. The diagnostic service falls 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 needle electromyography, (List separately in addition to code for primary procedure) (95886) provided July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services, medical examination provided on January 28, 2021.
You asked the Plan to waive the copayment for ophthalmological services, medical examination. The Plan denied your request. The Plan says the claim processed with the correct cost share.
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 $45 copayment for Vision Care. You have been asked to pay a $45 copayment for ophthalmological services, medical examination. The ophthalmological services, medical examination falls within the Vision Care 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 ophthalmological services, medical examination provided on
January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on
March 23, 2020, through March 28, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this provider furnished the services as a substitute physician in lieu of the attending physician.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that the patient's regular physician or physical therapist may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services which the regular physician or physical therapist arranges to be provided by a substitute physician or physical therapist on an occasional reciprocal basis. We find that CPT code 99233 is not supported in the record. Specifically, the record shows that these services were billed with modifier Q5 indicating that the services of a substitute physician were rendered. The record also shows that the services of the substitute physician were paid to the attending physician. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on March 23, 2020, through March 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on July 19, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you got a burn on your hand and would not have been able to drive to an urgent care or doctor's office because you do not drive. You also say that the paramedics were able to treat you without transporting you to the hospital. The Plan denied your request. The Plan says your request is not a covered benefit because your records show you refused transportation to the emergency room or hospital.
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 on July 19, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on July 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond January 10, 2022.
You asked the Plan to pre-approve the continued SNF care. You say that you feel that more SNF care is needed. The Plan denied your request. The Plan says daily skilled services are not required.
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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was treated in the hospital for a left heel infection. He was discharged to a SNF on 11/29/2021 with a wound vac. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are no longer required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, intermittent and custodial, can 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 the 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 beyond January 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B Injection, Ketorolac Tromethamine, administered during an Emergency Room (ER) visit on December 11, 2020.
You asked the Plan to waive the coinsurance for the Ketorolac Tromethamine. You say that there should not be any cost share. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the Ketorolac Tromethamine. This service falls within the Medicare Part B prescription drugs 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 coinsurance for
the Part B Injection, Ketorolac Tromethamine, administered during an Emergency Room (ER) visit on
December 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on March 31, 2021, billed with codes 36222-59-LT and 36225-50-59.
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 the services are not payable as they are not separate and distinct.
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 services as billed Our reviewer says that the use of modifier -59 is not support for these codes. Our physician reviewer found CPT 36222 59 LT is inclusive to CPT 36223 that was performed on March 31, 2021. However, a modifier is allowed to unbundle these services, providing the medical records support the use of an appropriate modifier. In this case, the medical records provided do not include sufficient documentation to append a 59 modifier to 36222 to unbundle this service, therefore, no additional payment is allowed for 36222 59 LT. CPT 36225 50 59 is
bundled with procedure 36226, which was performed on March 31, 2021. The use of a modifier is allowed to unbundle these services, providing the medical records support the use of an appropriate modifier. However, the medical records provided does not include sufficient documentation to support the use of the 59 modifier to unbundle these services, therefore, no additional reimbursement is allowed for 36225 50 59. 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 as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services provided on March 31, 2021, billed with codes 36222-59-LT and 36225-50-59.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for office visit. You say that you disagree with this denial. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on July 22, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye examination provided on
July 6, 2021.
You asked the Plan to waive the copayment for the eye examination. The Plan denied your request. The Plan says there is a $40 copay for a Medicare-covered exam to diagnose and treat diseases or conditions of the eye.
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 $40 copayment for Vision Care, Medicare-covered exams to diagnose and treat diseases or conditions of the eye. You have been asked to pay a $40 copayment for the eye examination. The eye examination falls within the Vision Care 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 an eye examination provided on July 6, 2021.