Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S1015, S8301) provided on May 12, 201.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes.
We looked at the file and Medicare rules. Codes S1015 and S8301 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 the services (S1015, S8301) provided on May 12, 201.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the member needs to do more physical work to help him move around. The Plan denied your request. The Plan says that the enrollee would not be able to perform 3 hours of therapy daily, 5 days a week.
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.
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical management of a tibia fracture. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endoscopy provided on April 16, 2021.
You asked the Plan to waive the copayment for the endoscopy. You say that the testing was not your choice and you should not be responsible for the copayment. 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 $225 copayment for each outpatient surgery at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay $189.17, which is less than the $225 copayment for the endoscopy. An endoscopy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 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 an endoscopy provided on April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for four bitewing X-ray images (D0274) and additional X-ray images (D0230) provided on September 13, 2021.
You asked the Plan to pay for bitewing X-rays and additional X-rays. You say that you do not recall using the Plan's dental services in the past as you have just started with the Plan. 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 2 series of bitewing films every year. 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 bitewing X-rays and additional X-rays have not been met. Specifically, the record shows that you received 2 sets of bitewing films on the same date of service. The case record demonstrates that the benefit for bitewing films has been exhausted for the year. Therefore, we decided that the Plan does not have to pay for four bitewing X-ray images (D0274) and additional X-ray images (D0230) provided on September 13, 2021.
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 enrollee meets the admission criteria.
You say that the clinical documentation provided supports the need for care in an LTACH. The Plan denied
your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's
care can be provided in the current inpatient hospital.
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 does not appear to be stable enough to transfer, however, additional
short-term acute care is needed and may safely be administered at the current facility. The enrollee does not
require services at the LTACH that are not already available at the current facility. There are no services at the
LTACH that the enrollee requires that are not already covered and available at the current facility. Transfer
would not be safe and would provide no clinical advantage at this time.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a total hip arthroplasty (27130) provided on
June 23, 2021.
You asked the Plan to waive the copayment for a total hip arthroplasty. You say that you called the Plan two
times prior to your surgery and were told both times that your copayment would be $198. The Plan denied your
request. The Plan says the correct copayment was applied.
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 $295
copayment for each Medicare-covered outpatient surgery at a hospital outpatient facility.
You have been asked to pay a $295 copayment for a total hip arthroplasty. A total hip arthroplasty falls within
the "Outpatient surgery, including services provided at hospital outpatient 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 a total hip arthroplasty
(27130) provided on June 23, 2021.
Your complaint about receiving inaccurate or incomplete information about your cost-sharing responsibilities
from representatives of the Plan is not a valid appeal for medical coverage. This part of your complaint is a
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types
of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a knee arthroplasty procedure (27447) provided on May 10 to May 14, 2021.
You asked the Plan to waive the coinsurance for a knee arthroplasty. You say that the assessed charge is awfully high. The Plan denied your request. The Plan says the correct coinsurance was applied.
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% coinsurance for surgery performed at an outpatient hospital facility. You have been asked to pay $2,249.67, or 20% of the Medicare-allowed total charge of $11,248.35, for a knee arthroplasty. A knee arthroplasty falls within the "Outpatient surgery, including services provided at hospital outpatient 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 coinsurance for a knee arthroplasty procedure (27447) provided on May 10 to May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not
been met.
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 a Vertiflex device. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy.
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 Vertiflex device have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Vertiflex device.
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 receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from July 12, 2020, through July 15, 2020.
You asked the Plan to pay for inpatient hospital care. You say that you submitted supporting documentation for reconsideration of adjustment. The Plan denied your request. The Plan says payment of DRG 871 is not supported. The Plan states the review supports DRG 592. The Plan states principal diagnosis code assignment of A41.9- Sepsis unspecified organism and secondary diagnosis code assignment of R65.20 - Severe sepsis without septic shock were reported by the hospital. The Plan states according to coding guidelines and documentation in the medical record these conditions did not qualify for reporting.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with A41.9- Sepsis unspecified organism, and secondary diagnosis code assignment of R65.20 - Severe sepsis without septic shock. 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 inpatient hospital care. Our physician reviewer found the review indicates that the documentation supported an admission for a sacral pressure ulcer. The documentation was inconsistent regarding a diagnosis of sepsis and severe sepsis. Even though sepsis is documented in the medical record, supporting documentation was not found. The review has determined that the following diagnoses codes were not supported by the records (principal diagnosis code assignment of A41.9- Sepsis unspecified organism, and secondary diagnosis code assignment of R65.20 - Severe sepsis without septic shock). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from July 12, 2020, through July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on June 21, 2021.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not covered under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on June 21, 2021.
Benefits for the 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair.
You asked the Plan to pre-approve a lightweight wheelchair. You say that this is necessary for the enrollee. The
Plan denied your request. The Plan says that Medicare will only purchase and maintain 1 mobility device.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have a transport chair. A transport chair serves the same purpose as a lightweight
wheelchair. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that it is not safe for you to be discharged yet. The Plan denied your request. The Plan says that you no longer appear to continue to benefit from or require daily skilled services.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (20930, 20936) provided March 10, 2021.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the claim cannot be paid 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 find that CPT codes 20930 and 20936 are not supported in the medical record. Specifically, the codes
billed have a status of "B" per the National Physician Fee Schedule. Payment for these services is always
bundled with payment for a primary procedure. Based on this information, we decided that Medicare rules for
coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay
for surgical services (20930, 20936) provided March 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee would benefit from rehabilitation in
the SNF for her fractured tibia and fibula. The Plan denied your request. The Plan says the enrollee has no
skilled care needs and the criteria for SNF coverage under Medicare have not been met.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications,
had stable vital signs, was treated for pain, and had clear lungs. The enrollee received physical therapy and
occupational therapy. The enrollee was at a supervision to contact guard assist level with functional mobility
including gait to 475 feet with a rolling walker. The enrollee required varying assist with activities of daily
living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service
needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a
SNF setting.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) manual physical therapy
techniques (97140) electrical stimulation (G0283) provided January 22, 2021 to July 26, 2021.
You asked the Plan to pay for the chiropractic service. You say that this provider was listed on the list
providers and you confirmed at the office that they were in network. Now you have received notice from the
Plan that the services are not covered. The Plan denied your request. The Plan says these services are not
covered when rendered by a chiropractor.
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the outpatient office visit (99202) manual physical therapy techniques
(97140) electrical stimulation (G0283) provided January 22, 2021 to July 26, 2021.