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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that all services that would be provided in the LTACH are being provided in the current acute care setting.

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. 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 he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140).

You asked the Plan to pay for the dental service. You say that you were advised that the service would be covered. The Plan denied your request. The Plan says 1 oral exam is covered every 6 months. The Plan also says that the frequency limit for this service 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.

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 frequency limit of 1 oral exam every 6 months has been exceeded. The record shows that the Plan paid for an oral exam that you received, less than 6 months prior. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140).
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 you would like intensive therapy to help you walk again. The Plan denied your request. The Plan says that it does not appear you could participate in intensive therapy.

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 complicated 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided by an out of network (OON) provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that the claim was denied for lack of authorization. However, provider is PAR. Further, previous claims for same codes and provider have been paid without issue. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 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 domiciliary or rest home visit (99336) provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work.

You asked the Plan to waive the copayment for the laboratory work. You say that you had the laboratory work done prior to your annual physical. You should not owe the copayment since the physical was cancelled and you will need to re-do the blood work. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for each category per service date (this copayment does not apply to interpretation costs) for x-rays, laboratory and other diagnostic tests.

You have been asked to pay a $9.12 copayment, which is less than the standard amount, for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the laboratory work.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy.

You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 Plan did not pre-approve the physical therapy. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physical therapy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy.

You asked the Plan to waive the copayment for a colonoscopy. You say that this should be considered a colonoscopy screening. 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 $175 copayment for outpatient surgery, including services provided at ambulatory surgical centers.

You received a colonoscopy. The record shows that you received the colonoscopy due hemorrhaging. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $175 copayment.

You have been asked to pay a $175 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a colonoscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a P-STIM device.

You asked the Plan to pre-approve a P-STIM device. You say that the requested P-STIM device is medically necessary. The Plan denied your request. The Plan says the requested P-STIM device is not medically necessary.

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 a P-STIM device. Our reviewer says that the requested P-STIM device is not medically necessary. Our physician reviewer found at issue is whether percutaneous electrical nerve stimulation (PENS) device requested here, P-STIM is a covered service under Medicare rules. The PENS coverage diagnostic procedure which involves stimulation of peripheral nerves by a needle electrode inserted through the skin is performed only in a physician's office, clinic, or hospital outpatient department. Therefore, it is covered only when performed by a physician or incident to physician's service. If pain is effectively controlled by percutaneous stimulation, implantation of electrodes is warranted. As in the case of TENS, generally the physician should be able to determine whether the patient is likely to derive a significant therapeutic benefit from continuing use of an implanted nerve stimulator within a trial period of 1 month. In a few cases, this determination may take longer to make. The medical necessity for such diagnostic services which are furnished beyond the first month must be documented.

In this case, the requested device is an electro-acupuncture device per https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K140788. Such devices are not covered by Medicare. In addition, the request for payment under the PENS rule requires percutaneous placement of the electrode. The requested device does not have this feature. Therefore, coverage of the requested device cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a P-STIM device have not been met. Therefore, we decided that the Plan does not have to pre-approve a P-STIM device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the specialist services.

You asked the Plan to pay for the specialist services. You say that you did not know you needed a referral. The Plan denied your request. The Plan says you did not have a referral for the services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that a referral is required for services from a specialist. 

You did not have a referral and the Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the specialist services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says prior authorization was not obtained.

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 Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services.

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 procedure code 99283 is not supported.

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 99283 is Level 3 emergency department visit for evaluation and management of patient with problem of moderate severity, including expanded problem-focused history and physical examination, and medical decision-making of moderate complexity. 

We find that CPT code 99283 is not supported in the medical record. Specifically, the records do not support a Level 3 ER visit. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services.
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 admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with dehydration, cerebral vascular accident and diabetes. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. His lungs were clear. Regarding rehabilitation services, the enrollee had received physical therapy in the acute hospital. The enrollee was at a contact guard to minimal assist level with functional mobility including gait to 70 feet.

There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a SNF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210).

You asked the Plan to pay for the dental service. You say that the provider took x-rays. You say that this is the first time you had x-rays so it should be covered. You also say that you do not have money to pay for the x-rays. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service. The Plan also says that there is no record that you called to verify your benefits prior to the date of 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 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 complete series x-ray (D0210).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID testing.

You asked the Plan to pay for these services. You say that you had the testing done to enter the nursing home at which your mother is residing. The Plan denied your request. The Plan says the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The Plan contract says that COVID testing is not covered when performed on an asymptomatic individual in order to allow them to visit patients in nursing homes and other facilities.

The test at issue in this appeal, a COVID-10 test, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. The test is not covered by your supplemental benefit with the Plan because it was performed to allow you to visit a patient in a nursing home. Therefore, we decided that the Plan does not have to pay for the COVID testing.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services.

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 procedure code 99283 is not supported.

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 99283 is Level 3 emergency department visit for evaluation and management of patient with problem of moderate severity, including expanded problem-focused history and physical examination, and medical decision-making of moderate complexity.

We find that CPT code 99283 is not supported in the medical record. Specifically, the records do not support a Level 3 ER visit. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve continued use of a continuous positive airway pressure (CPAP) device for the enrollee.

You asked the Plan to pre-approve continued coverage. You say that this is medically necessary. The Plan denied your request. The Plan says that the compliance reports do not meet the requirements.

The Plan must follow Medicare rules. Medicare rules say that continued CPAP coverage can be provided if there is a clinical re-evaluation 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 continued coverage. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has obstructive sleep apnea. She has been prescribed CPAP, but has not been able to meet minimum usage requirements of at least 4 hrs/night for at least 70% of nights. She was clinically re-evaluated, and issues of mask discomfort are being addressed. It is medically reasonable and necessary to provide the patient with one more opportunity to meet minimum usage requirements. CPAP coverage should be extended an additional 3 months. If the enrollee is not able to meet minimum usage requirements during that time, CPAP will be considered not medically necessary, and further coverage denied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued coverage have been met. Therefore, we decided that the Plan has to pre-approve continued use of a continuous positive airway pressure (CPAP) device for the enrollee.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting.

You asked the Plan to pay for the self-administered drugs. You say that the drugs you were given are included on the formulary list for your insurance. You say that your insurance should cover these. You also say that you do not have the money to pay for this bill. The Plan denied your request. The Plan says the drugs that you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting.