Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress (E0265).

You asked the Plan to pay for a total electric hospital bed. You say that the item should be covered. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pay for a hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress (E0265).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the enrollee can obtain services at a lower level of care.

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 not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs and the enrollee does not require an intensive rehabilitation 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. Specifically, the enrollee can obtain services at a lower level of care. This means that IRF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that further rehab would prepare the enrollee for
unexpected obstacles at home. The Plan denied your request. The Plan says the enrollee does not need to be
seen by a rehab doctor at least three times a week.

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 was admitted to the acute hospital for sepsis, urinary tract infection, and metabolic
encephalopathy. His medical conditions are stable. There are no medical needs requiring an inpatient
admission. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies,
including either physical or occupational therapy, in an intensive 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for the Part B drug. We decided that the Plan does not
have to waive the coinsurance for the Part B drug.

You asked the Plan to waive the coinsurance for the Part B drug. You say that you were told there would not be
a coinsurance. The Plan says that you have been charged the correct cost sharing amount.

We decided that the Plan has to reduce the coinsurance for the Part B drug.

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles, and coinsurance). The records show that the allowed amount for the Part B
drug is $1,036.15. ($1,036.15 x 20% = $207.23).

The Plan says that you must pay $210.60 for the Part B drug. Based on the plan contract, however, you cannot
be asked to pay more than a $207.23 for the Part B drug. Therefore, we decided that the Plan has to reduce the
coinsurance for the Part B drug from $210.60 to $207.23.

We also decided that the Plan does not have to waive the coinsurance for the Part B drug.

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 20%
coinsurance for the Part B drug. Therefore, we decided that the Plan does not have to waive the coinsurance for
the Part B drug.

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 the Iv tubing extension set coded S1015 and the Infection control supplies coded S8301

You asked the Plan to pay for the Iv tubing extension set and the Infection control supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these services are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the Iv tubing extension set and the Infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the Infection control supplies coded S8301
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you were not aware that these services would not be covered by your insurance. You also say that you cannot afford to pay for these expenses out-of-pocket. The Plan denied your request. The Plan says these services were rendered by an OON 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided by an OON provider.
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. The Plan denied your request. The Plan says you will not benefit significantly from an intensive rehab program.

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 you were admitted to the acute hospital for pneumonia, and then were discharged to a skilled nursing facility where physical and occupational services are provided. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing needs. You do not require treatment, including either physical or occupational therapy, in an intensive 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 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 preapprove
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 myocardial infarction and
cardiac arrest. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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 medical record documents a need for physical and occupational therapy, it does not document a need
for an intensive 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 IRF admission and services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on October 7, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because the lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says that screening services with no relation to a medical diagnosis of disease for the health of the member are not a benefit.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

The enrollee was referred for the laboratory services by a contract provider. The file does not show that the plan provided notice that the laboratory services would not be covered. Additionally, the diagnosis indicates that this testing is directly related to the members diagnosis. This is not a screening service. Under Medicare rules, this means the laboratory services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory services provided on October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274).

You asked the Plan to pay for the bitewing x-rays. You say that this service is covered under your Plan. You also say that you contacted the Plan prior to receiving the service and verified coverage. The Plan denied your request. The Plan says the frequency limit for this service had been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, bitewings are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0274), and your bitewing x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274).
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 enrollee is unable to perform basic functions safely. The Plan denied your request. The Plan says the enrollee does not need three hours of rehab therapies per day.

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 was admitted to the acute hospital for surgical repair of an aortic dissection and replacement of aortic valve. Her medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing needs. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 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 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 elective coronary artery bypass grafting. Medical conditions are stable. There are no medical
needs requiring inpatient admission. 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 medical record documents a need for physical and
occupational therapy, it does not document a need for an intensive 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve continued CPAP coverage.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that continued coverage cannot be provided.

The Plan must follow Medicare rules. Medicare rules say that there can be continued coverage of CPAP if there is documented adherence to 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates in February 2021 that you were compliant with the use of the CPAP. The need for re-evaluation is not relevant in this case because by the wording of the rule, the reevaluation refers to the initial period of use, not every subsequent renewal. Therefore, the enrollee meets the criteria for coverage and continued CPAP coverage is 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 the services have been met. Therefore, we decided that the Plan has to pre-approve continued CPAP coverage.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the admission is medically necessary. The Plan denied your request. The Plan says services could be obtained at a lower level of care.

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 not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require an intensive rehabilitation program or have any medical needs that would require admission to 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. Specifically, the enrollee can obtain services at a lower level of care. This means that admission to an IRF is not medically necessary or reasonable for this enrollee. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee's
clinical condition does not require skilled nursing care as an inpatient.

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 pre-approve SNF services. Our physician reviewer
found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. There
are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee received speech therapy
at a non-skilled level for dysphagia. There are no identifiable skilled therapy service needs. The enrollee does
not require skilled nursing or therapy services on a daily basis. He does not meet severity of illness or intensity
of service criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care procedures (11043, 11046, and 17250).

You asked the Plan to pay for wound care procedures. You say that these procedures are documented. The Plan
denied your request. The Plan says these codes are not supported in the records.

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 11043 is debridement, muscle and/or fascia (includes
epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less. The definition of 11046 is
debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each
additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure). The definition of
17250 is chemical cauterization of granulation tissue (i.e., proud flesh).

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 wound care procedures. Our reviewer says
that these codes are not supported. Our physician reviewer found the operative report does not include enough
documentation to confirm CPT 11043 was performed. There is a more appropriate code to report for this size
wound. The wound is 2.0 cm deep, meaning it would be inappropriate to report CPT 11046. Per CPT
guidelines, CPT 17250 should not be reported when chemical cauterization is used to achieve wound
homeostasis. Per Operative report, "Hemostasis was obtained using silver nitrate chemical cauterization and
pressure." Therefore, this code should not be reported for this service.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of wound care procedures have not been met. Therefore, we decided that the Plan
does not have to pay for wound care procedures (11043, 11046, and 17250).