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

We decided that the Plan does not have to pay for the skilled nursing services provided from January 21, 2019 to February 24, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 21, 2019 to February 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 occupation therapy (OT) visits.
You asked the Plan to pre-approve the visits. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on review of the provided medical records, the enrollee has already had 12 occupational therapy sessions including a session on March 2, 2020. She has been instructed on a home exercise program and she has a splint. Further occupational therapy sessions are not necessary. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 occupation therapy (OT) visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered to the enrollee on June 27, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 definitive drug testing rendered to the enrollee
on June 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on June 19, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you did not know you were being sent to an out-of-network facility. The Plan denied your request. The Plan says the copayment applied 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 $240 copayment for CT scans performed in an in-network outpatient hospital facility or free standing facility. You have been asked to pay a $240 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that you were charged the in-network cost. 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 CT scan provided on June 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's needs are met in the current acute care hospital.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 patient is currently undergoing treatment at an acute care hospital (ACH) for syndrome of inappropriate antidiuretic hormone secretion in the setting of stage IV cancer. Aggressive treatment for the cancer is not being pursued. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe chiropractic manipulative treatment (98940) provided by out of network (OON) provider on February 1, 2019.You asked the Plan to pay forthese services. You say that while in Florida you developed acute neck pain and sought treatment from a chiropractic clinic instead of going to the emergency room.The Plan denied your request. The Plan says that the services were provided by an out of network provider without prior authorization. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care.  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 these services. Our reviewer says that the services provided were medically necessary and reasonable. Our physician reviewer found that youcould not have foreseen requiring the services prior toleaving yourservice area. Additionally, it would not have been medically reasonable to delay the services until you returned to yourservice area.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pay forthe chiropractic manipulative treatment (98940) provided by the out of network (OON) provider on February 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a food thickener (B4100).You asked the Plan to pre-approve the food thickener. You say that you have a condition which requires the food thickener. The Plan denied your request. The Plan says there is no reimbursement available for this service.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. We looked at your request, the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage have not been met. Specifically, per the Medicare OPPS Fee Schedule, this service has a status indicator of E1. This means that this service is not payable by Medicare. Therefore, we decided that the Plan does not have to pre-approve a food thickener (B4100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for reconstruction of mandible (21249) provided May 1, 2019.
You asked the Plan to pay for the dental services. You say that you have lost all upper teeth due to medication you take for fibromyalgia. You also have TMJ. You get muscle spasms and severe pain when you try to wear your dentures. The Plan denied your request. The Plan says this service is not covered as a dental procedure and not medical in nature.
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 reconstruction of mandible (21249) provided May 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, cone beam CT capture and interpretation, and endodontic therapy provided on November 12, 2019.You asked the Plan to pay forthe limited oral evaluation, intraoral periapical x-rays, cone beam CT capture and interpretation, and endodontic therapy. You say that you were informed that your tooth was infected and needed a root canal as soon as possible. You also say that this provider was the first endodontist who could see you within a timely manner.The Plan denied your request. The Plan says you received these dental services from a non-contracted provider with no referral.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 covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, cone beam CT capture and interpretation, and endodontic therapy provided on November 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from May 31, 2019 to June 9, 2019.You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not receive skilled physical therapy services after May 30, 2019. The Plan also says that the enrollee received comfort and routine care as a custodial resident during this time.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from May 31, 2019 to June 9, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay forinjections (96372, Q5106) provided from September 12, 2019 to September 26, 2019.You asked the Plan to pay forinjections. You say that the services were medically necessary.The Plan denied your request. The Plan says that the enrollee did not meet criteria in this case.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pay for injections. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was treate for myelodysplastic syndrome with Neupogenand Epogen. The services on these dates of service were medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injections have beenmet. Therefore, we decided that the Plan has to pay forinjections (96372, Q5106) provided from September 12, 2019 to September 26, 2019.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 toopen the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital 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. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH). The enrollee was intubated/ventilated upon presentation and received a tracheotomy just a few days later. The documentation does not yet establish that weaning has been reasonably attempted and failed. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH to receive any required acute 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110) and fillings (D2331 and D2332) provided December 16, 2019.
You asked the Plan to pay for the dental services. You say that the provider told you that he accepted the plan. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.
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. Services must be rendered by a participating dental provider. 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 cleaning (D1110) and fillings (D2331 and D2332) provided December 16, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are requesting inpatient rehab verses LLOC, as she has rehab goals that include returning to her previous level of care. The Plan denied your request. The Plan says that this request is not considered medically necessary and care can be provided at a lower level.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found the enrollee has a new ostomy and the complexity of the member's nursing, medical management and rehabilitation needs require an inpatient stay and an interdisciplinary team approach to the delivery of her rehabilitation care. She is unable to perform essential activities of daily living without assistance and requires an intensive rehabilitation therapy program. The enrollee had been independent prior to admission supporting the expectation that she will show a measurable, practical improvement in her functional status within a reasonable period of time. The enrollee has therapy and medical needs that meet criteria for acute level rehabilitation. Care at a lower level would not effectively meet her rehabilitation 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95909) and needle electromyography (95885) provided June 25, 2019.You asked the Plan to pay for nerve conduction studies and needle electromyography. You say that the services were medically necessary.The Plan denied your request. The Plan says nerve conduction studies and needle electromyography are not supported 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.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 nerve conduction studies and needle electromyography. Our reviewer says that nerve conduction studies and needle electromyography are not supported by the medical records. Our physician reviewer found the medical records submitted do not include documentation of Nerve conduction studies; 5-6 studies. CPT code 95885 is an add-on code. Medicare states that "An add-on code is eligible for payment if and only if one of its primary codes is also eligible for payment".We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nerve conduction studies and needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95909) and needle electromyography (95885) provided June 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for the enrollee.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says the enrollee is medically stable, and does not need daily oversight of physicians.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 physician reviewer found that the enrollee's medical conditions appear stable. There is no complex wound care needs. There are no unaddressed medical issues. She does not require medical oversight of her condition at an acute hospital level of care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. She is limited by debility. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program.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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee