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 enrollee requires more intense rehabilitation therapy than is available at a lower level of care. The Plan denied your request. The Plan says an IRF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on January 6, 2020.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you were told this procedure was mandatory and that no copayment was requested at the time of the services. You said that you are unable to afford this bill. 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 $200 copayment for outpatient surgery at an ambulatory surgery center. You have been asked to pay a $200 copayment for the diagnostic colonoscopy. According to the medical records, this colonoscopy was performed because you had increased rectal bleeding that required evaluation. In addition, you had polyps removed during this procedure. That is why the diagnostic colonoscopy falls within the outpatient surgery at an ambulatory surgery center 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 you had on January 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy provided by a participating provider.
You asked the Plan to pre-approve physical therapy. You say that all 12 additional physical therapy sessions are medically necessary. The Plan denied your request. The Plan says they will approve 7 out of the 12 requested physical therapy sessions.
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 pre-approve physical therapy. 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 he additional seven approved therapy sessions appear to be adequate to finalize a home exercise program going forward. Records do not document why the now 19 approved physical therapy visits are inadequate to treat the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on June 1, 2021.
You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says the claim processed correctly.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan process the claim correctly. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services provided on April 2, 2021, by
an OON provider.
You asked the Plan to pay for the surgical pathology services. You say that the patient was seen by a network
physician, however, there were no in-network laboratories able to provide the appropriate medical care. The
Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
record shows the referring provider is out-of-network. Therefore, we decided that the Plan does not have to pay
for the surgical pathology services provided on April 2, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies (99072), the IV tubing extension set (S1015), and the infection control supplies (S8301) provided on April 22, 2021.
You asked the Plan to pay for the equipment and supplies. You say that you would like these services reprocessed based on the medical documentation. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and Medicare rules. Code 99072 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made as payment is bundled into the payment for the services to which this code is incident to. Codes S1015 and S8301 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes.
Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the additional supplies (99072), the IV tubing extension set (S1015), and the infection control supplies (S8301) provided on April 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308)
rendered by the OON provider from February 16, 2021, through February 25, 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.
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 subsequent nursing facility care, per day (99308) rendered by the OON
provider from February 16, 2021, through February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the flow cytometry (88185 and 88184) provided on February
23, 2021.
You asked the Plan to pay for the flow cytometry. You say that you would like reconsideration because this
claim should be processed at the in-network benefit level. The Plan denied your request. The Plan says CPT or
HCPCS procedure codes with a CMS PC/TC indicator of 3 are technical component only codes and are not
considered eligible for reimbursement by a physician in a facility place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT codes 88185 and 88184 are not supported in the record. Specifically, CPT codes 88185 and 88184 have a PC/TC indicator of 3 and are considered technical component only codes. Payment for these services is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the flow cytometry have not been met. Therefore, we decided that the Plan does not have to pay for the flow cytometry (88185 and 88184) provided on February 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 10 physical therapy visits.
You asked the Plan to pre-approve the additional physical therapy visits. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the additional
physical therapy is not medically reasonable and necessary.
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 pre-approve the additional physical therapy visits.
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 member is at a functional level that
does not require skilled therapy. The requested services are not part of a maintenance program, are the
specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a
program to maintain the member'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 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve an additional 10 physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899).
You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental for the enrollee's condition.
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 an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental. More research is needed to show it is safe and effective for low back pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your
request. The Plan says that needs can be met in a lower level of care.
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 SNF care. Our reviewer says that the
requested admission is medically reasonable and necessary. Our physician reviewer found you do qualify for
SNF coverage. You have documented skilled therapy, and are functioning below your late August baseline.
The documentation does not yet establish that you have reached a new plateau in function. A period of daily
skilled services is reasonably required to establish a maintenance program, prevent deterioration of your
condition and improve strength and endurance.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve admission to a
skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on May 14, 2021.
You asked the Plan to pay for the physical therapy services. You say that the medical records required to reprocess the denied claim are attached. The Plan denied your request. The Plan says the records do not support the code billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on May 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 home health skilled nursing visits.
You asked the Plan to pre-approve 8 home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 8 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent 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 8 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical services in a specialist's office (99213, 17000, 17003) rendered on February 25, 2021.

You asked the Plan to waive the copayment for surgical services in a specialist's office. You say that you were charged two copayments The Plan denied your request. The Plan says you were charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for each specialist's office visit.

You have been asked to pay a total of a $10 copayment for the surgical services in a specialist's office. Surgical services in a specialist's office fall within the Outpatient Surgery, including services Provided at Hospital Facilities and Ambulatory Surgical Centers 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 surgical services in a specialist's office (99213, 17000, 17003) rendered on February 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) provided on July 14, 2021.
You asked the Plan to waive the copayment for the MRI. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for radiological diagnostic services. You have been asked to pay a $125 copayment for the MRI. The MRI 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 the magnetic resonance imaging (MRI) provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on May 11, 2021, by an out-of-network provider.
You asked the Plan to pay for dental services. You say that you should have received some amount of reimbursement for the services of the out-of-network dentist. The Plan denied your request. The Plan says rules for payment have not been met.
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 dental services when provided by a network provider. We looked at the file, the Plan contract, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met because services were rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for dental services provided on May 11, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0800).
You asked the Plan to pre-approve a power scooter. You say that you need this because you otherwise cannot take care of yourself. The Plan denied your request. The Plan says you are able to use a walker.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 a power scooter. Our reviewer says that the requirements for coverage have not been met. Our physician reviewer found the record indicates that you have oxygen dependent chronic obstructive pulmonary disease. The records indicate that you are able to use a walker but are limited by fatigue. The requested item is to allow increased mobility in a living facility. The records provided are inconsistent in the description of your capabilities, being more favorable after the original request. The record does not sufficiently support that limitations of mobility related activities of daily living are
present. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0800).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87481, 87798, 88305, 88312)
rendered by the out-of-network (OON) provider on June 5, 2020.
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.
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 laboratory services (87481, 87798, 88305, 88312) rendered by the out-of-network (OON) provider on June 5, 2020.