Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care services provided by a licensed professional counselor from November 17, 2020, to December 8, 2020.

You asked the Plan to pay for outpatient mental health care services. You say that you are appealing with documentation of your non-Medicare status for these claims to be reconsidered. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is not eligible to participate in Medicare and is not payable.

The Plan must follow Medicare rules. Medicare rules say that to receive payment for items or services, a provider must be enrolled in the Medicare program. Medicare rules also say that a licensed professional counselor is not eligible to enroll in the Medicare program.

We looked at the file and Medicare rules. This provider is not eligible to participate in Medicare and is not payable. Based on this information, we decided that Medicare rules for coverage of outpatient mental health care services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health care services provided by a licensed professional counselor from November 17, 2020, to December 8, 2020.
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay 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. The enrollee was admitted for syncope, rectal bleeding, anemia, and hypotension. He was treated for ulcerative colitis. The enrollee developed a blood clot in leg and ultimately had a below the knee amputation. The enrollee was transferred to skilled nursing facility on February 26, 2021, where they are receiving therapy now. 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 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 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 acute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physical therapy.
You asked the Plan to pre-approve the physical therapy. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while the enrollee is a member of our Plan, the enrollee must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.
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 and accessible who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided from October 7, 2020, to November 4, 2020.
You asked the Plan to waive the copayments for specialist visits. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for specialist visits. You received specialist visits from October 7, 2020, to November 4, 2020 for a total of 5 visits. Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $175. You have been asked to pay the total copayment amount of $175 for specialist visits. Specialist visits fall within the physician/practitioner services, including doctor's office visits 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 copayments for specialist visits provided from October 7, 2020, to November 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you feel that you need rehabilitation to strengthen your muscles and learn to use equipment. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (CPT 99203 and CPT 36590) provided to the enrollee on October 28, 2020.
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 this was not billed correctly.
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 the denied codes is: CPT 99203: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of decision making CPT 36590: Removal of peripheral venous catheter for infusion We asked our coding 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. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found per the CMS Global Surgery Booklet page 10 of 19 "In addition to the CPT E/M code, modifier "-57" (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery. The modifier "-57" is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and visitor consultation is not billed in addition to the procedure. MACs may not pay for an E/M service billed with the CPT modifier "-57" if it was provided on the day of, or the day before, a procedure with a 000-010 day gloval surgical period." Therefore, billing CPT 99203 with modifier 57 is not appropriate. CPT 36590 is not supported by the documentation submitted. The documentation does not include documentation of removal of peripheral venous catheter for infusion.
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 physician services (CPT 99203 and CPT 36590) provided to the enrollee on October 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).

You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Synvisc-One. Our reviewer says that Synvisc-One is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drugs, Orthovisc and Monovisc. Our physician reviewer also found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211).

You asked the Plan to pre-approve the maxillary partial denture. You say that you need this denture to be approved for coverage. The Plan denied your request. The Plan says this service exceeds 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 (D5211) and is limited to one procedure every five plan years. The record shows that you received a maxillary partial denture (D5211) on August 3, 2017 and your maxillary partial denture (D5211) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5211).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says a step therapy exception cannot be granted.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Orthovisc and Monovisc. Based on the medical records provided, there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement power wheelchair.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the current chair is less than five years old, and there is no documentation of irreparable damage.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that a replacement chair is required at less than five years. The available records do not document that the current chair is irreparably damaged. There is no evidence that the chair has been lost or stolen.

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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement power wheelchair.
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 these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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 aninterdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to pain, fatigue and decreased endurance. 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: 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 only intense therapy will help you return to baseline.
The Plan denied your request. The Plan says that you do not require inpatient rehab from a medical standpoint.
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for a fall and was treated for sepsis
and a urinary tract infection. 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.
Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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's medical status does not require intensive physician and nursing oversight in an IRF. The enrollee may benefit from multiple therapies, including physical and occupational therapy but the documentation does not support that the enrollee requires this therapy on an intensive rehabilitation 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amniofix for suspension 160mg.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that the drug is helpful for treatment of nerve pain of lower limb during decompression neuroplasty.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental and investigational for use during decompression neuroplasty. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Amniofix for suspension 160mg.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office consultations to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve office consultations to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network specialists available to you that can provide the care you are requesting.

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 office consultations to be provided by an out of network (OON) provider.