Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the mammogram provided on January 12, 2021.

You asked the Plan to waive the deductible for the mammogram. You say that you have never paid for any part of a mammogram which is covered under your Plan. You say that payment of the bill should be authorized. The Plan denied your request. The Plan says the deductible applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. 

The item or service you asked the Plan to waive the deductible for falls within the "Breast cancer screening (mammograms)" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the mammogram was received by an out-of-network provider on January 12, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the mammogram provided on January 12, 2021.
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 can tolerate 3 hours of therapy and needs medical oversight to continue his progress. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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. While the enrollee does require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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: 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 the enrollee's doctors recommend IRF care. The Plan
denied your request. The Plan says rules for IRF care have not been met.

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. The
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational
therapy but there is no documented need for an intensive 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 that there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan.
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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January
27, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that you got a cleaning and should be no
cost to you. 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. Therefore, we decided that the Plan does not have to pay for the
periodontal maintenance (D4910) provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dentures (D5130, D5212) and 17 surgical tooth extractions (D7210).

You asked the Plan to pre-approve dentures and 17 surgical tooth extractions. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are 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, dentures are not covered under this benefit. Only one extraction, which has been approved by the Plan, is covered each year. Therefore, we decided that the Plan does not have to pre-approve dentures (D5130, D5212) and 17 surgical tooth extractions (D7210).
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 IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 patient was admitted to an acute care hospital for weakness, decreased appetite, failure to thrive and a metastatic lumbar spine lesion for which lumbar laminectomy was performed. Medical conditions 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. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953), first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep sedation/general anesthesia (D9223), and therapeutic parenteral drugs (D9612) provided on February 5, 2021.
You asked the Plan to pay for the bone replacement graft, deep sedation/general anesthesia services, and therapeutic parenteral drugs. You say that you feel that these services should be covered. The Plan denied your request. The Plan says these services are not covered by the 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 pay for the bone replacement graft for ridge preservation (D7953), first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep sedation/general anesthesia (D9223), and therapeutic parenteral drugs (D9612) provided on February 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on your current status, intensive interdisciplinary therapies are not required and IRF placement is not needed. Your needs can be met at a skilled nursing facility.
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 weakness. Your medical conditions 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. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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 an IRF admission and services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you need SNF services. The Plan denied your request. The Plan says that your records do not show the daily skilled services needed can only be provided on an inpatient basis in a SNF.
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 services are medically reasonable and necessary. Our physician reviewer found based on the documentation provided, that the enrollee does qualify for SNF coverage. The enrollee does have documented skilled nursing needs, requiring twice daily dressing changes. The enrollee does have documented skilled therapy needs, as he is currently functioning below his baseline. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of 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 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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the craniectomy or craniotomy for evacuation of hematoma services coded 61312 provided on April 25, 2020.
You asked the Plan to pay for the craniectomy or craniotomy for evacuation of hematoma services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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. In this case, the CPT Code Manual definition of code 61312 is craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural.
We find that CPT code 61312 is not supported in the medical record. Specifically, this code was billed with modifier 78. This modifier is not covered when the same or different 0, 10 or 90-day procedure code has not been billed on the same day for a code with a 0-day post-operative period, on the same day or in the previous 10 days for a code with a 10-day post- operative period, or on the same day or in the previous 90 days for a code with a 90-day post-operative period. Based on this information, we decided that Medicare rules for coverage of the craniectomy or craniotomy for evacuation of hematoma services have not been met. Therefore, we decided that the Plan does not have to pay for the craniectomy or craniotomy for evacuation of hematoma services coded 61312 provided on April 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on February 22, 2021.

You asked the Plan to pay for the complete series of intraoral x-rays. You say that you would like this service to be covered. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.

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, full mouth or panoramic x-rays are limited to one procedure code every five years. The record shows that you received a complete series of intraoral x-rays on February 15, 2021 and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on January 25, 2021 by an OON provider.
You asked the Plan to pay for the crown. You say that this service should be covered at 50%. The Plan denied your request. The Plan says you are responsible for the difference between the in-network fee schedule (INFS) and dentists' charged fees when visiting an OON dentist. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
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, you are responsible for a 75% coinsurance for crowns that are received OON, plus the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the crown provided on January 25, 2021 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of June 23, 2021.
You asked the Plan to pre-approve inpatient psychiatric care. You say that you cannot be safely discharged
because of your level of confusion and history of violence. The Plan denied your request. The Plan says the
denial of authorization for continued inpatient psychiatric care is correct, because you can be treated in a lower
level of care such as outpatient.
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 you do not meet the Medicare criteria for continued inpatient psychiatric care. Our physician reviewer
found it is not expected that you would improve in a reasonable period of time beyond June 22, 2021, as you
were not showing any dangerousness to self or others, auditory or visual hallucinations, aggressive behaviors,
or any acute threats to safety. You were cooperative and compliant with medication. It does not appear
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather
than a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continued inpatient psychiatric care as of June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve a portable oxygen concentrator. You say that this request is necessary for you to travel. The Plan denied your request. The Plan says this benefit is only covered by Medicare for home use.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the comprehensive oral evaluation, prophylaxis, first intraoral periapical x-ray, additional intraoral periapical x-ray, and bitewing x-rays provided on January 4, 2021 by an OON provider.
You asked the Plan to pay more for the comprehensive oral evaluation, prophylaxis, intraoral periapical x-rays and bitewing x-rays. You say that you were advised that this provider was in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that you are responsible for the difference between the in-network fee schedule (INFS) and dentists' charged fees when visiting an OON dentist.
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 intraoral x-rays are not among those covered under this benefit. The contract says that you are responsible for a 50% coinsurance for comprehensive oral evaluation, prophylaxis, and bitewing x-rays, plus the difference between the billed amount and allowed amount, for services received OON. The record shows that your provider contacted the Plan, and the Plan representative gave the provider network benefit information because the provider stated that they were a network provider with the Plan. The provider was told that the Plan was code specific and did not verify if intraoral x-rays were covered or not. The record also shows that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility. Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation, prophylaxis, first intraoral periapical x-ray, additional intraoral periapical x-ray, and bitewing x-rays provided on January 4, 2021 by an OON provider.