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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis and can receive further rehabilitation services at 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250 x 2), guided tissue regeneration (D4266), bone replacement graft (D2953), a crown (D2750), surgical placement of an implant body (D6010 x 2), retainer crowns (D6752 x 2), and pontic (D6245).

You asked the Plan to pre-approve the dental services. You say that you need these services. You say that your previous dentist passed away just before the coronavirus. You also say that the dentists that purchased the practice are horrible in comparison. The Plan denied your request. The Plan says the provider in this case is not contracted with the Plan. The Plan says that to be covered in network, you must use a provider that is contracted with our dental vendor to provide supplemental dental services. The Plan also says that there is a contracted dentist that can render these services.

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, to be covered in network, you must use a provider that is contracted with our dental vendor to provide supplemental dental services. Therefore, we decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250 x 2), guided tissue regeneration (D4266), bone replacement graft (D2953), a crown (D2750), surgical placement of an implant body (D6010 x 2), retainer crowns (D6752 x 2), and pontic (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Infrared Wand (E0691) received by the enrollee on January 21, 2021.

You asked the Plan to pay for the infrared wand. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use.

The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for the Infrared Wand (E0691) received by the enrollee on January 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. 

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. Specifically, medically necessary services can be obtained at a lower level of care. THis means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from
November 27, 2020, through December 26, 2020.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says continuation of SNF services 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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, the enrollee no longer qualified for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point were custodial and, as a practical matter, could be provided at a lower level of care (ex. home, assisted living, long term 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from November 27, 2020, through
December 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence testing provided on January 26, 2021.
You asked the Plan to pay for the services provided. You say that the test identifies potential targeted therapy options. The Plan denied your request. The Plan says the procedure was unlikely to impact therapeutic decision making.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. In this case, the CPT Code Manual definition of code 81455 is targeted genomic sequence analysis panel for 51 or greater genes. The rules say that this genetic testing is unlikely to impact therapeutic decision making in the clinical management of the enrollee. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence testing provided on January 26, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 9, 2021, to February 11, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you believe the denial decision should be reversed. The Plan denied your request. The Plan says that the acute inpatient hospital stay was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from February 9, 2021, to February 11, 2021.
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) therapeutic exercises (97110) manual therapy techniques (97140) provided November 14, 2020 to December 22, 2020.

You asked the Plan to pay for the chiropractic services. You say that you had checked chiropractic coverage online and it did not mention plan chiropractors but rather a limit on coverage. Please process reimbursement as if an in-network claim since this was not clear in the instructions. 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 (99203) therapeutic exercises (97110) manual therapy techniques (97140) provided November 14, 2020 to December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture (D5110).
You asked the Plan to pre-approve the complete upper denture (D5110). You say that the patient presents with an ill-fitting denture that is falling out and choking him. You say that this makes eating, speaking and functionable use of the denture impossible and the decision should be reconsidered to avoid any serious risks. The Plan denied your request. The Plan says dentures are only covered once every 5 years.
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 Plan also has a maximum benefit of one complete upper denture every 5 years. The plan paid for a complete upper denture provided on May 3, 2018, which exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper denture (D5110
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture with a flexible base (D5225).
You asked the Plan to pre-approve the denture. You say that the enrollee cannot tolerate dentures with a metal base, and flexible dentures are necessary. The Plan denied your request. The Plan says this type of denture is not covered by the Plan's dental benefit.
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 a partial upper denture with a flexible base (D5225).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for inpatient services (CPT 99356) provided to the enrollee on November 10, 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 that the documentation supports additional unit/floor time spent by the provider.
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 99356 is "inpatient services (CPT 99356) provided to the enrollee on November 10, 2020." 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 supported by the medical records. Our coding reviewer found the physician progress note clearly documents in detail the services performed during the visit, as well as other team members and the enrollee's family and friends. The provider also documents the time to support prolonged services. Therefore, the services should be covered. 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 been met. Therefore, we decided that the Plan has to pay for inpatient services (CPT 99356) provided to the enrollee on November 10, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee on February 24, 2021.
You asked the Plan to pay for the monitor. You say that this falsely denied claim will only delay care for the enrollee. The Plan denied your request. The Plan says there is evidence of misrepresented services.
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 pay for the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found although some of the form says that the enrollee takes three shots of insulin per day, there is no mention of the regimen including Humalog or Novolog. There is only a mention of Tresiba, which is a once daily insulin. Ozempic is a once a week treatment. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary for this enrollee. The Plan denied your request. The Plan says the enrollee is currently receiving the appropriate inpatient care and a transfer to an LTACH would provide no clinical advantage.

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 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 they are currently receiving care.

The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Therefore, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99309) provided on December 3, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that for conditions with both an underlying etiology and multiple body system manifestations due to the underlying etiology, the ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Specifically, the record shows that the claim was billed with primary diagnosis code F01.51. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. 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 (99309) provided on December 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF 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 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 the health plan's denial should be upheld. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program 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 not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam computed tomography scan (D0364) provided on April 28, 2021.

You asked the Plan to pay for a cone beam computed tomography scan. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

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 a cone beam computed tomography scan (D0364) provided on April 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the cystoscopy procedure provided on
December 30, 2020.
You asked the Plan to waive the copay for the services provided. You say that the doctor failed to do the final
diagnostic test. The Plan denied your request. The Plan says the claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300
copay for outpatient surgery.
The cystoscopy procedure at issue is considered a surgical service. You have been asked to pay a $300 copay
for the services provided. The services fall within the outpatient surgery 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 copay for the cystoscopy procedure provided on December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 9, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 9, 2020 by an out-of-network (OON) provider.