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

We decided that the Plan has to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed 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 care. Our physician reviewer found there are identifiable skilled nursing service needs. There
are identifiable skilled therapy service needs. The beneficiary does require skilled nursing or therapy services
on a daily basis. This beneficiary does 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 SNF care have been met. The Plan
must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service
and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the
Plan has to pre-approve SNF care.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for two ultrasounds provided by a participating provider on July 2, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have 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 $110 copayment for outpatient diagnostic tests/radiological diagnostic services. You have been asked to pay a $110 copayment for an ultrasound. The total amount you are being asked to pay is $220 ($110 x 2 ultrasounds = $220). An ultrasound falls within the outpatient diagnostic tests/radiological diagnostic services 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 two ultrasounds provided by a participating provider on July 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the soft tissue of the neck.You asked the Planto pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the chest CT is approved and the soft tissue of the neck CT is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of recurrent pleural effusions, chronic kidney disease on home dialysis, and breast cancer. She has recent complaints of hoarseness, nasal and chest congestion, and wheezing. The requested CT scan of the soft tissue of the neck for a complaint of hoarseness is not reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the soft tissue of the neck
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site (D4266), surgical placement of implant body: endosteal implant (D6010), second stage implant surgery (D6011), custom fabricated abutment - includes placement (D6057), abutment supported porcelain fused to metal crown (high noble metal) (D6059) and bone graft at time of implant placement (D6104).
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
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. The services are not listed in your manual as a covered benefit; therefore, they are not covered. Therefore, we decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site (D4266), surgical placement of implant body: endosteal implant (D6010), second stage implant surgery (D6011), custom fabricated abutment - includes placement (D6057), abutment supported porcelain fused to metal crown (high noble metal) (D6059) and bone graft at time of implant placement (D6104).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing care services provided on June 15, 2020, by an
out-of-network (OON) provider.
You asked the Plan to pay for the nursing care services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 has network providers
available who can provide 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 nursing care services provided on June 15,
2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea fixed bridge, consisting of two retainer crowns for teeth #2 and 4 and a pontic for tooth #3.You asked the Plan to pre-approvethe fixed bridge. You say that this bridge is needed in order for you to eat food and to avoid infection.The Plan denied your request. The Plan says this is not a covered service under your dental benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea fixed bridge, consisting of two retainer crowns for teeth #2 and 4 and a pontic for tooth #3
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.The Plan must follow Medicare rules. Therules 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. Long term acute care hospitals are certifiedas acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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-approvelong term acute care hospital (LTACH) services for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 13, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
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
physician's services. 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 physician's services provided on November 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services and wound care provided by a participating provider on September 9, 2020, to September 24, 2020.You asked the Plan to waive the copayment forphysician services and wound care. You say that you did not know this was considered an outpatient surgery. The Plan denied your request. The Plan says the correct copayments have 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 $275 copayment and a $40 copayment for outpatient surgery/network/outpatient hospital and physician/practitioner services/network/specialist. You have been asked to pay a $275 copayment for wound care and a $40 copayment for physician services Physician services falls within the physician/practitioner services/network/specialist benefit category and wound care falls within the outpatient surgery/network/outpatient hospital 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 physician services and wound care provided by a participating providr on September 9, 2020, to September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital outpatient clinic visit (G0463) and radiologic examination, ankle (73610) provided on July 1, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe outpatient visit. You say that claim denied for no authorization. Please review medical records and process for payment.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 has network providers available who can provide the items/services at issuein 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 forthe hospital outpatient clinic visit (G0463) and radiologic examination, ankle (73610) provided on July 1, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forcritical care services provided on March 6, 2020, through March 7, 2020.You asked the Plan to pay forthe critical care services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation does not include the time spent providing this service.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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.We find that CPT code 99291 is not supported in the record. Specifically, the documentation submitted does not include the amount of time spent rendering critical care services. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met.Therefore, we decided that the Plan does not have to pay forcritical care services provided on March 6, 2020, through March 7, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe home health visit provided on June 13, 2020 billed with code 99348.You asked the Planto pre-approvethe home visit. You say that this was correctly billed and should be paid.The Plandenied your request. The Plansaysthis cannot be paid since the physician was not present.The Plan must follow Medicare rules. Medicare rules say that billing for services described by code 99348 requires the physical presence of the billing physician in the enrollee's home.The documentation for this date of services shows that the enrollee was seen by a certified nursing assistant. There is no evidence that the physician was physically present.Therefore, we decided that the Plandoes not haveto pre-approvethe home health visit provided on June 13, 2020 billed with code 99348.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontic - porcelain fused to noble metal (D6242), core
buildup, including any pins when required (D2950) and endodontic therapy, premolar tooth (excluding final
restoration) (D3320).
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied
your request. The Plan says the services are not a covered benefit under the plan.
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. The services are not listed in your handbook as a covered benefit;
therefore, they are not covered. Therefore, we decided that the Plan does not have to pre-approve pontic -
porcelain fused to noble metal (D6242), core buildup, including any pins when required (D2950) and
endodontic therapy, premolar tooth (excluding final restoration) (D3320).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that your functional status requires or could tolerate an 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-approveacute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory services provided on October 1, 2019, through October 11, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like reconsideration based on the records submittedThe Plan denied your request. The Plan says the submitted medical documentation and/or claim history indicates that the specimen was obtained in an outpatient rehabilitation setting and the documentation submitted did not include a valid physician order/lab requisition or medical records.The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. The rules also say that the physician must clearly document, in the medical record, his or her intent that the test be performed.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the record indicates that the specimen was collected in an outpatient rehab setting, and therefore POS 81 is not appropriate. Additionally, therecord does not include documentation of the physician's intent for the tests to be performed.Therefore, we decided that the Plan does not have to pay forlaboratory services provided on October 1, 2019, through October 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran X-ray provided on July 23, 2020.You asked the Plan to waive the copayment foran X-ray. You say that you disagree with the charges because you received the X-ray in your primarycare providers office.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 $10 copayment for X-rays. You have been asked to pay a $10 copayment for an X-ray. An X-ray falls within the diagnostic services/labs/imaging 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 foran X-ray provided on July 23, 2020
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the knee brace (CPT Code L1851).
You asked the Plan to pre-approve the knee brace. You say that the orthosis is necessary. The Plan denied your
request. The Plan says that the Medicare rules have not been met.
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 knee brace. Our physician reviewer
found despite lack of instability, patient has lateral pain documented on exam. The patient may benefit
symptomatically by stability support.
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 knee brace have been met. Therefore, we decided that the Plan has to preapprove
the knee brace (CPT Code L1851).
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: 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 you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.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 theLTACH services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with falls and bilateral subdural hematomas. Recent notes state that he has been diagnosed with encephalopathy and is still dependent on mechanical ventilation. He does not require services at the LTACH that are not already available at the current setting. There are no services at the current setting that the enrollee requires that are not already available and covered at the current setting. The LTACH services are not reasonable or medically 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.