Persius/hicric huggingface dataset:
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 SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found Based on the documentation provided, you do not have documented skilled nursing needs. In addition, you do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. You care needs, as a practical matter, can be provided at a lower level of 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 SNF care 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on June 2, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for genetic testing. You say that you would like this appeal reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that the member's primary care physician did not refer these services.
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 genetic testing provided on June 2, 2020 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent auto-injector.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan
denied your request. The Plan says this drug is not covered by Medicare Part B and the Plan does not
administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pre-approve Praluent auto-injector.
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 23, 2021.

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 lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.

The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
rendered on March 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that services can be provided 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 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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from November 9, 2019 to November 15, 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 the submitted records do not support the billing of DRG 065 and diagnosis code N39.0.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 065 and diagnosis code N39.0 (urinary tract infection, site not specified). 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 submitted records do not support the billing of DRG 065 and diagnosis code N39.0. Our physician reviewer found the enrollee presented with confusion and gait instability following a fall earlier in the week. Magnetic resonance imaging (MRI) was obtained and he was diagnosed with an acute ischemic stroke. While Neurology indicated that the most likely common cause of the enrollee's confusion was the urinary tract infection (UTI), the UTI was not clinically valid. There was a positive urinalysis; however, the clean catch urine culture showed no significant growth. Documentation supported that the urine culture was collected prior to the start of antibiotics. Given that the UTI was not valid, and there was no alternate etiology of the enrollee's confusion, the enrollee's altered mental status can be primarily attributed to the stroke. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from November 9, 2019 to November 15, 2019.
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 the enrollee's medical needs are being met in the current acute
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 waive the copayment for three pontics (D6240) and four retainer crowns (D6750) to make up two fixed bridges provided on November 13, 2020.

You asked the Plan to waive the copayment for the dental services. You say that you are being overcharged for these services. The Plan denied your request. The Plan says the cost-sharing for these services has been applied correctly, and they contacted the provider to ensure that you are not being balance billed. You had two dental bridges done on the date in question, comprised of three pontics and four retainer crowns, and you are responsible for $1,960 for the services.

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 between $20 and $425 for each prosthodontic service. Specifically, a porcelain fused to high noble metal pontic (D6240) requires a $220 copayment and each porcelain fused to high noble metal retainer crown (D6750) requires a $325 copayment. 

You have been asked to pay $1,960 for the dental services. On the date in question, you received two fixed bridges comprised of pontics and retainer crowns. Fixed bridges can be made up of a variety of types of retainer crowns and pontics and cover varying numbers of teeth, so bridges are billed and charged by the procedures and components that make them up. The first bridge, from tooth #11 to tooth #13, contains two retainer crowns and one pontic. The second bridge, from tooth #2 to tooth #5, contains two retainer crowns and two pontics. Each of the three pontics you received requires a $220 copayment ($220 x 3 pontics = $660). Each of the retainer crowns you received requires a $325 copayment ($325 x 4 retainer crowns = $1,300). Therefore, the total cost of services comes to $1,960 ($1,300 + $660 = $1,960). 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 three pontics (D6240) and four retainer crowns (D6750) to make up two fixed bridges provided on November 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the medical records do not support the need for the requested inpatient psychiatric service admission.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. You do not appear to require inpatient mental health treatment as you are not a danger to yourself or others and were cooperative and compliant. It does not appear that active treatment is taking place. It does not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on February 9, 2021.
You asked the Plan to waive the coinsurance for radiation therapy services. You say that you could have done surgery for free but was advised of radiation treatment. You say that you were never told there was 20% coinsurance. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance per visit for radiation therapy.
You have been asked to pay $63.65, which is 20% of the allowed amount for radiation therapy services. The allowed amount is $318.23 (20% x $318.23 = $63.65). Radiation therapy services 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 coinsurance for radiation therapy services provided on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) provided on January 19, 2021.

You asked the Plan to pay for the incisional biopsy. You say that this service is a medical procedure. You also say that the treating provider participates with Medicare. The Plan denied your request. The Plan says this service is not valid for Medicare coverage.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. This service was billed as dental a dental service by the out-of-network provider and as such, cannot be covered as a medical service without the proper medical code being submitted along with records to support medical necessity. Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit to be provided by an out-of-network provider.
You asked the Plan to pay for an office visit. You say that you would like approval to see this doctor. The Plan denied your request. The Plan says that these services can be provided in-network.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The response for information that we received was a corrupt file; therefore, an unfavorable decision could not be made. Therefore, we decided that the Plan has to pay for an office visit to be provided by an out-of-network provider.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 2, 2021 to March 31, 2021.

You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a RAP claim was not billed.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the record indicates that a RAP claim has not been submitted. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 2, 2021 to March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for rehabilitation services provided from November 12, 2019, through May 12, 2020.

You asked the Plan to pay for the rehabilitation services. The Plan denied your request. The Plan says after review, it was determined that the claim does not meet the urgent or emergent criteria based on the diagnosis code submitted. There is also no indication that any attempt was made to obtain prior authorization for the rendered services.

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 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 rehabilitation services provided from November 12, 2019, through May 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that you are losing control of your blood sugar and your overall health. The Plan denied your request. The Plan says that you do not meet Medicare criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of a neurostimulator.

You asked the Plan to pre-approve percutaneous implantation of a neurostimulator. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that coverage of PNS trials requires that patients meet specific criteria. 

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 percutaneous implantation of a neurostimulator. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no indication for a spinal cord stimulation (SCS). The request is not medically reasonable or 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 percutaneous implantation of a neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of a neurostimulator.