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

We decided that the Plan does not have to waive the copayment for the outpatient hospital observation stay, and the inpatient hospital stay provided from September 3, 2020, to September 10, 2020.
You asked the Plan to waive the copayment for the outpatient hospital observation stay, and the inpatient hospital stay. You say that you are being charged twice for your hospital rooms. You say this was a planned surgery. The Plan denied your request. The Plan says you have been asked to pay 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 $250 copayment per stay for each in-network Medicare-covered service and a $250 copayment for each in-network Medicare-covered hospital stay.
You have been asked to pay a $250 copayment for the outpatient hospital observation stay and a $250 copayment for the inpatient hospital stay. The outpatient hospital observation stay falls within the "Outpatient Hospital Observation" benefit category. The inpatient hospital stay falls within the "Inpatient Hospital Care" benefit category. The medical record shows you were in observation for the September 3, 2020 to September 4, 2020 hospital stay. The medical record shows you were admitted to the hospital as an inpatient after an emergency room visit from September 6, 2020, to September 10, 2020, which is considered a separate hospital stay.
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 outpatient hospital observation stay, and the inpatient hospital stay provided from September 3, 2020, to September 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that inpatient psychiatric care continues 
to be medically necessary. The Plan denied your request. The Plan says inpatient psychiatric care is no longer 
medically necessary as you are medically stable. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer 
says that inpatient psychiatric care is not medically reasonable and necessary. Our physician reviewer found 
you are a 65-year-old female who was admitted to the acute inpatient psychiatric hospitalization on March 30, 
2021 with Major Neurocognitive Disorder due to Alzheimer's disease with Behavioral Disturbance and Major 
Depressive Disorder, Recurrent, Severe without Psychotic Features. You do not appear to require inpatient 
mental health treatment beyond the date in question as you are not a danger to yourself or others and did not 
have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services were reasonably 
expected to improve your condition or for the purpose of diagnosis beyond the date in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of inpatient psychiatric care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will not thrive, and depends on his 
siblings to provide care for him. The Plan denied your request. The Plan says this request 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 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. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. Our physician reviewer also 
found that there is not a reasonable expectation that this enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate maxillary partial denture (D5221).

You asked the Plan to pre-approve the immediate maxillary partial denture. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.

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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an immediate maxillary partial denture (D5221).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and mandibular
partial denture (D5214).

You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that
the partials are medically necessary. The Plan denied your request. The Plan says these services exceed the
maximum count allowed per period.

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, maxillary partial denture and
mandibular partial denture are each limited to one procedure every five plan years. The record shows that the
enrollee received a maxillary partial denture (D5211) and a mandibular partial denture (D5212) and 
the enrollee's maxillary partial denture and mandibular partial denture benefits have been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) 
and mandibular partial denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you want to be at a facility that offers a better
outcome for wounds. 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 your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
congestive heart failure, sepsis and lower extremity wounds. You were transferred to a skilled nursing facility
on March 30, 2021. Your medical problems are stable. There are no complex nursing or rehabilitation
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2313, E2377, E2311), power seat elevation system (E2300), and active reach (K0108).

You asked the Plan to pre-approve an expandable controller, power seat elevation system, and active reach. You say that these items are medically necessary. The Plan denied your request. The Plan says these items are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that a power seat elevation feature is non-covered. The rules also say that an expandable controller is covered when it is medically necessary to accommodate proportional input devices, non-proportional input devices. to operate 3 or more powered seating actuators, to operate a separate display, other electronic devices, or an attendant control.

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 expandable controller. Our reviewer says that the expandable controller is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the expandable controller is medically necessary for any of the functions listed in the Medicare rules section. You have adequate strength and coordination of her upper extremities to control the power options with their own switches based on the records provided.

The active reach device at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. In addition, the power seat elevation feature will not be covered. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2313, E2377, E2311), power seat elevation system (E2300), and active reach (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for out-of-network behavioral health services.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there is a network provider available.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral for out-of-network behavioral health services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve the SNF services. You say that you do not feel comfortable going home just yet. The Plan denied your request. The Plan says you do not meet Medicare guidelines because you are receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility. Considering economy, efficiency and treatment consistent with the nature and severity of your illness with the accepted standards of medical practice, you are receiving the appropriate care in the Inpatient Rehabilitation Facility. Movement to a skilled nursing facility is not medically necessary.

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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the medical records, you have stabilized medically and you have been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). You have tolerated inpatient rehab services and continue to improve with daily skilled nursing and/or skilled therapy services. You could benefit from continued services at the current level of care. You have made slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. You can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care when appropriate. There are no services offered at a SNF that are not offered at an IRF. Admission to a SNF for inpatient skilled rehab services is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (87150, 87482, 87500, 87640, 87653, 
87798, 87799) provided on November 27, 2020. 
 
You asked the Plan to pay for laboratory testing. You say that these tests were ordered by the treating 
physician. The Plan denied your request. The Plan says the diagnosis on the claim does not meet coding 
standards. 

The Plan must follow Medicare rules. Medicare rules say that A "use additional code" note on an infectious 
disease diagnosis code indicates a need for the organism code to be added as a secondary code. 
 
We looked at the file and Medicare rules. The billed diagnosis, N39.0 (urinary tract infection, site not 
specified), has a "use additional code" note. A secondary diagnosis is required but was not present on the 
claim. Based on this information, we decided that Medicare rules for coverage of laboratory testing have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory testing (87150, 87482, 
87500, 87640, 87653, 87798, 87799) provided on November 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 16, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until October 8, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on May 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction. 
 
You asked the Plan to pre-approve the surgical extraction. You say that you would like this service to be 
covered. The Plan denied your request. The Plan says this service is not covered. 
 
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 requested items or services are not 
among those covered under this benefit. The only extractions that are covered under your plan are simple 
extractions. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel the rehab facility could help you walk again. 
The Plan denied your request. The Plan says this request 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. Our physician reviewer also found that there is not a 
reasonable expectation that you 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral device/appliance used to reduce upper airway 
collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment (E0486) 
provided September 29, 2020. 
 
You asked the Plan to pay for the oral device. You say that thank you in processing this reconsideration. You 
are providing documentation to support medical necessity. The Plan denied your request. The Plan says the 
records do not support the billed service. 
 
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 physician order. 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 oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom 
fabricated, includes fitting and adjustment (E0486) provided September 29, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee has no one to assist him full time. 
You also say that the enrollee is not able to care for himself. The Plan denied your request. The Plan says there 
is no need for daily skilled therapy services to be provided by a skilled therapist on a daily basis, and no daily 
skilled nursing needs. 
 
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 
the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does 
not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that requires the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing 
and/or skilled therapy on 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. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Therefore, we decided that the Plan does not have to pre-approve 
the SNF services.