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

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be
medically necessary for the enrollee. The Plan denied your request. The Plan says SNF care is no longer
medically necessary for the enrollee.

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 the continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found in this case, the
patient has no complex wound care or other skilled nursing need. The patient's functional level does not require
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to
safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered
date. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an
inpatient basis, in a skilled nursing facility setting beyond the last covered date.

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 continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued care in the skilled nursing facility (SNF) beyond March 15, 2021.
You asked the Plan to pre-approve the continued SNF care. You say that you feel that you require more skilled care before you can leave. The Plan denied your request. The Plan says you do not require daily skilled care at this time.
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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this patient does not require ongoing skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The patient has no complex wound care or other skilled nursing need. The patient's functional level does not require ongoing skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.
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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued care in the skilled nursing facility (SNF) beyond March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (E0297).
You asked the Plan to pre-approve the total electric hospital bed. You say that this is necessary for your condition. The Plan denied your request. The Plan says this is not a covered service.
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 pre-approve the total electric hospital bed (E0297).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a recumbent bike purchased May 24, 2020.
You asked the Plan to pay for a recumbent bike. You say that this device is helpful for your medical condition. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal, exercise equipment, does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a recumbent bike purchased May 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for inpatient hospital care provided from September 2, 2020, through September 7, 2020, by an in-network provider.
You asked the Plan to waive the cost-sharing for inpatient hospital care. You say that you were billed $728.48 for room and board on a surgery you had and upon reviewing your 2020 out of pocket (OOP) maximum, you should have only been billed $701.14. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were inpatient for 5 days, from September 2, 2020, through September 7, 2020, ($150.00 x 5 = $750.00). The claims were reviewed and the benefits correctly applied. Regarding the explanation of benefits (EOB) dated November 3, 2020, (the claim you are appealing), the out-of-pocket (OOP) remaining on your EOB showed $15.41. This includes the adjustment of three (3) claims. These claims originally indicated a patient responsibility which, after adjustment, were reduced to $0.00 and removed from the total OOP paid for the 2020 plan year. The claims were adjusted after the fact impacting the OOP amount and reducing it prior to reapplying those amounts to other claims. If you have already paid the patient portion of those claims in the form of Copay and/or Coinsurance, you should anticipate a refund if no other funds are owed to the provider. 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 cost-sharing for inpatient hospital care provided from September 2, 2020, through September 7, 2020, by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost sharing applied to the medical services provided from June 16, 2020, to November 4, 2020.
You asked the Plan to adjust the cost sharing applied to the medical services. You say that you believe that it is not fair for you to pay more than the Plan for the services you receive. You believe that all services that you paid more than the Plan should be adjusted so you pay less. The Plan denied your request. The Plan says the cost sharing has been correctly 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 set copayments for different categories of medical services. We have reviewed the claims at issue where you have been asked to pay more than the Plan. We find that the copayments were correctly applied. There is no provision in the contract which would require the Plan to reduce a copayment when it would result in you owing more for the service than the Plan. 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 adjust the cost sharing applied to the medical services provided from June 16, 2020, to November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental consultation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON dental consultation. You say that you went to your network dentist, and he was not able to fix your crown. You believe that you should be able to go OON to see if someone else can. The Plan denied your request. The Plan says you are restricted to network providers. There is no evidence that only this OON provider can provide you with necessary services covered by the Plan.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a dental consultation to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-electric hospital bed.
You asked the Plan to pre-approve the semi-electric hospital bed. You say that you would like reconsideration because this bed is necessary for the member who requires positioning of the body in ways that are not feasible with an ordinary bed. The Plan denied your request. The Plan says there is no documentation to support member has a medical condition that requires positioning of the body in ways not feasible with an ordinary bed
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that the member does not meet Medicare coverage criteria for the semi-electric hospital bed. Our physician reviewer found there is no documentation to support that the member has a medical condition that requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or requires head of bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease or problems with aspiration, requires traction equipment which can only be attached to a hospital bed, requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve the semi-electric hospital bed.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the prolonged evaluation and management service (99358).

You asked the Plan to pay for the prolonged evaluation and management service. You say that you would like
reconsideration because this code is a stand-alone code and can be billed before or after direct patient care. The
Plan denied your request. The Plan says that this service may not be reported separately.

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 coder 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 prolonged evaluation and management service. Our
reviewers says that CPT code 99358 meets criteria for billing and reimbursement consideration. Our reviewer
found CPT 99358 is a stand-alone code and can be reported on two separate calendar days.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the prolonged evaluation and management service. have been met. Therefore,
we decided that the Plan has to pay for the prolonged evaluation and management service (99358).

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide therapeutic continuous glucose monitor supplies.
You asked the Plan to provide therapeutic continuous glucose monitor supplies. You say that the enrollee needs supplies for a therapeutic continuous glucose monitor. The Plan denied your request. The Plan says the enrollee does not meet criteria for a therapeutic continuous glucose monitor.
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. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day or uses insulin with at least three daily injections. If the enrollee does not meet criteria for a therapeutic continuous glucose monitor the supplies are not covered also. Based on this information, we decided that Medicare rules for coverage of therapeutic continuous glucose monitor supplies have not been met. Therefore, we decided that the Plan does not have to provide therapeutic continuous glucose monitor supplies.
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 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. 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 urinary tract infection and a COVID 19 infection. Medical problems are stable. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a CT scan. You say that you would like approval for this. The Plan denied your request. The Plan says there are in-network providers available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a CT scan to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee will benefit from physical therapy at least five times per week, but this can be carried out in a lower level of care.
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 there is no documentation provided necessitating admission to a LTACH. 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. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services and office visit provided by an out of network (OON) provider.

You asked the Plan to pay for the chiropractic services and office visit. You say that you were informed by the provider that they were a participating provider in your plan's network. The Plan denied your request. The Plan says the provider is not a participating provider in the plan's network, and you were not referred by an in-network provider.

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. A Plan physician must refer you before you can get care from a chiropractor. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the chiropractic services and office provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery percutaneous decompression.

You asked the Plan to pre-approve spinal surgery percutaneous decompression. 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 PILD is covered under specific circumstances. 

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 spinal surgery percutaneous decompression. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no clear discussion to support the medical necessity of minimally invasive surgery over standard lumbar decompression (in the setting of severe right neuroforaminal stenosis with potential nerve root impingement which cannot typically be fully addressed with minimally invasive surgery). Therefore, this 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 spinal surgery percutaneous decompression have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery percutaneous decompression.