Persius/hicric huggingface dataset:
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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical resection of a meningioma Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive,
multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient facility fee provided by a participating provider on March 17, 2021.
You asked the Plan to waive the copayment for an outpatient facility fee. You say that you never had this procedure done. You say that the doctor told you it was not necessary. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 copayment for outpatient hospital services/in-network.
You have been asked to pay a $290 copayment for an outpatient facility fee. This copayment is applied to the outpatient hospital facility visit; therefore, the correct copayment has been applied. An outpatient facility fee falls within the outpatient hospital services/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient facility fee provided by a participating provider on March 17, 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 IRF care is medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF have not been met. The Plan says that the enrollee's needs may be safely met in the current hospital setting.
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 low back pain and sacral fractures. The enrollee's 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0427 and A0425) provided on February 10, 2021.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the member was transported via ambulance 5 times on the same date of service. The Plan denied your request. The Plan says Medicare rule for payment of an additional ambulance trip for February 10, 2021, due to lack of appropriate documentation has not been met.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Specifically, the record indicates that the Plan has paid for two trips from the member's facility to the hospital. The documentation submitted does not support that a third trip to the hospital was rendered. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0427 and A0425) provided on February 10, 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 the 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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have any documented skilled therapy or skilled nursing needs. 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the retreatment of previous root canal therapy provided on April 26, 2021.
You asked the Plan to pay more for the retreatment of previous root canal therapy. You say that you wouldn't have taken the coverage or done the work, but the representative told you it was covered. The Plan denied your request. The Plan says the claim reprocessed to pay up to your $1,000 maximum.
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 is only obligated to pay up to your $1,000 maximum for your covered dental services. You pay 100% of charges beyond the $1,000 allowance. Therefore, we decided that the Plan does not have to pay more for the retreatment of previous root canal therapy provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid provided on December 31, 2020.
You asked the Plan to pay for the hearing aid. You say that the Plan referred you to an outside facility to get a hearing aid. You say that you want to know why you are not being reimbursed. The Plan denied your request. The Plan says the hearing aid was purchased from a non-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are received from a network provider. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid provided on December 31, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for needle electromyography (95870) and continuous intraoperative neurophysiology monitoring (G04530) provided on February 12, 2021.
You asked the Plan to pay for the needle electromyography and continuous intraoperative neurophysiology monitoring. You say that you would like reconsideration because these services were medically necessary and billed correctly. The Plan denied your request. The Plan says that CPT code 95870 has been denied as it is incident-to another service and G0453 has been priced per the provider contract.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, there is no indication as to what the primary procedure code is or why CPT code 95870 would be denied as incident-to another paid procedure. Additionally, CPT code G0453 was denied as being priced per the provider's contract. This is not a valid argument when the provider is not contracted with the Plan. The Plan has indicated that this provider is out-of-network and the file includes a waiver of liability form to verify this. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for needle electromyography (95870) and continuous intraoperative neurophysiology monitoring (G04530) provided on February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88312, 88305, 88361) provided to the enrollee on March 4, 2021.
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 is rejected as a duplicate claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 88312, 88305, 88361 are not supported in the medical record. Specifically, for CPT 88312 and 88305, the professional and technical components of these services have already been paid. The total component cannot be submitted again for payment. In terms of CPT 88361, eight units were reported, and the plan paid six. The final two units cannot be paid, because these extra units exceed the medically unlikely value (MUE) for this 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 laboratory services (88312, 88305, 88361) provided to the enrollee on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality test (D0460) provided on March 18, 2021.

You asked the Plan to pay for the dental service. You say that you had an infection on your tooth. You say that you had a temporary filling placed. You also say that you expect the services to be covered. The Plan denied your request. The Plan says pulp vitality test is not listed as a covered service.

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 pulp vitality test is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulp vitality test (D0460) provided on March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of current medical literature shows that this device does not have proven benefit and is considered experimental and investigational.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no records from the treating medical provider recommend this device - only those from vendor/manufacturer. The current guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided on March 18, 2021.
You asked the Plan to pay for a limited oral evaluation, and an intraoral periapical radiographic image. You say that the services were necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided on March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and an
expandable controller (E2377, E2313, E2311) for a power wheelchair.
You asked the Plan to pre-approve the seat elevation feature and expandable controller. You say that the
expandable controller and seat elevation feature are medically necessary. The Plan denied your request. The
Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that power seat elevation features are non-covered.
Expandable controllers are covered when medically necessary.
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 seat elevation feature and
expandable controller. Our reviewer says that the seat elevation feature and expandable controller are not
medically necessary. Our physician reviewer found the enrollee is capable of operating the covered power features using the standard switches. Seat elevation functions are not covered under Medicare rules.
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 seat elevation feature and expandable controller have not been met.
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and an
expandable controller (E2377, E2313, E2311) for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary
for the enrollee's pain. The Plan denied your request. The Plan says this procedure is considered
experimental/investigational.
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 Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy of the device.
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 Vertiflex procedure have not been met.
Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on May 7, 2021.
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 certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, 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 only diagnosis code F02.81. 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 provided on May 7, 2021.
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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for acute kidney insufficiency, anemia, bacteremia and bradycardia requiring pacemaker placement. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for mental health services received on April 28, 2021, and May 6, 2021.

You asked the Plan to waive the copayment for the services. You say that it was your understanding that psychological visits were covered during the pandemic. The Plan denied your request. The Plan says the policy liberalization ended as of April 21, 2021.

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 $40 copayment for outpatient mental health care. 

You have been asked to pay a $40 copayment for the services. The services fall within the outpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for mental health services received on April 28, 2021, and May 6, 2021.