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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after July 25, 2021.

You asked the Plan to pre-approve SNF care. You say that your spouse is physically incapable of providing the assistance you need. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on 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 not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after July 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient psychiatric admission provided from November 17, 2020, through December 28, 2020.

You asked the Plan to pay for the inpatient admission. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollee has improved and is no longer a threat to himself or others.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for continuation of the admission provided from November 17, 2020, through December 28, 2020. Our reviewer says that continuation of the inpatient services provided from November 17, 2020, through December 28, 2020 is not considered medically reasonable and necessary in this case. Our physician reviewer found that based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The enrollee was cooperative and compliant with medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of November 17, 2020 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of the admission provided from November 17, 2020, through December 28, 2020 have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient psychiatric admission provided from November 17, 2020, through December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided to you by an out-of-
network provider from February 18, 2021, to March 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
covered out-of-network. 
 
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 services at issue in this appeal. 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 the chiropractic services provided to you by an out-of-network 
provider from February 18, 2021, to March 22, 2021.
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 no longer requires the services of acute inpatient level of care. The Plan denied your request. The Plan says the enrollee does not have acute medical conditions and is not capable of participating in intensive therapy 3 hours a 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 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 physician reviewer found that the enrollee was admitted to the acute care hospital for sepsis, pneumonia, hyponatremia and pulmonary fibrosis. He was discharged to skilled nursing and was subsequently discharged with home health services. His medical conditions are stable. He does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehab 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 21, 2020.

You asked the Plan to pay for the laboratory services. 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 supported by the documentation.

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 87633, 84439, 84443, 82728, 82977, 83036, 83655, 83825, 80061, 82175, 82300, 82306, 82495, 86141, 87798, 83090, 82607, 86328, 87486, 87581, 84270, 84402, 84403, 84550, 84481, 85025, 82746, 83615, 84144, 84202, 80053, 82533, 82627, and 82670 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on March 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the enrollee could not choose an in-network optometrist. The Plan denied your request. The Plan says prior authorization was not obtained prior to the services 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 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 the ophthalmology services provided on March 5, 2021 by an out-of-network
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided August 11, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this request reprocessed and approved for payment. The Plan denied your request. The Plan says there is no evidence the provided item was medically reasonable.

The Plan follows Medicare rules. Medicare rules say that a lumbar-sacral orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically reasonable and necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of the back. 

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided August 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
October 7, 2020, to October 31, 2020. 
 
You asked the Plan to pay for the SNF services provided from October 7, 2020, to October 31, 2020. You say 
that you would like the services to be paid. The Plan denied your request. The Plan says there is no 
documentation of daily skilled therapies after October 6, 2020. 
 
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 pay for the SNF services provided from October 7, 
2020, to October 31, 2020. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. 
Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services provided from October 7, 2020, to October 31, 2020 have not 
been met. Specifically, the records did not show that the enrollee received daily skilled services after October 
6, 2020. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services 
provided from October 7, 2020, to October 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
February 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the office consultation (99241) rendered by the out-of-network (OON) provider on February 4, 2021.

You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered to you by an out-of-network provider that does not participate in the Medicare program.

The Plan must follow Medicare rules. The contract with the Plan says that you can receive your care from
in-network and out-of-network providers; however, if you obtain services from an out of network provider, they must participate with Medicare. 

We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the office consultation have not been met. Specifically, the service was provided by an
out-of-network provider that does not participate in the Medicare program. Additionally, the Plan contract states that you will be responsible for the full cost of the services you receive if the provider does not participate with Medicare. Therefore, we decided that the Plan does not have to issue reimbursement for the office consultation (99241) rendered by the out-of-network (OON) provider on February 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion Device Placement Surgery for the enrollee.

You asked the Plan to pre-approve these services. You say that the enrollee needs these services to treat lumbar spinal stenosis with neurogenic claudication. The Plan denied your request. The Plan says that xperimental and investigational procedures are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. Our physician reviewer found that the enrollee's condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion Device Placement Surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient eye services rendered by the out-of-network (OON) provider from February 9, 2021, through March 25, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the outpatient eye services rendered by the out-of-network (OON) provider from February 9, 2021, through March 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on December 1, 2020, to
December 22, 2020.

You asked the Plan to pay for the services provided. You say that you were in danger of losing your vision. The
Plan denied your request. The Plan says the services do not meet the coverage criteria for out-of-country
benefits.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.

We looked at the file and Medicare rules. The need for surgery services was known prior to leaving the service area. There are insufficient medical records to show that the services were urgent, emergent, or unable to wait until you returned to the service area. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on December 1, 2020, to December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a presbyopia correcting function of intraocular lens (V2788)
provided on December 1, 2020, to December 22, 2020.

You asked the Plan to pay for a presbyopia correcting function. You say that you do not understand why the
payment was denied. The Plan denied your request. The Plan says this service is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a
conventional IOL.

While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for a presbyopia correcting
function of intraocular lens (V2788) provided on December 1, 2020, to December 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation provided on January 8, 2021.
You asked the Plan to pay for the ambulance transportation. You say that the services are separate from the inpatient facility services and should be paid separately. The Plan denied your request. The Plan says the enrollee was inpatient when the ambulance services were rendered, and the claim processed correctly. Once a member is admitted to an inpatient hospital or critical access hospital (CAH), it may be necessary
to transport the member to another hospital or other site temporarily for specialized care while the member
maintains inpatient status with the original provider.
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital, it may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered "patient transportation" and is covered as an inpatient hospital service
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance transportation have not been met. Specifically, the record shows that the enrollee was admitted as inpatient to the origin location provider. The record also shows that the enrollee was moved to another provider while maintaining inpatient status with the original provider. This means that the ambulance service is covered as an inpatient hospital service and is not separately billable. Therefore, we decided that the Plan does not have to pay for ambulance transportation provided on January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April
10, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.

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 services at issue in this appeal. 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 the services provided by an out-of-network provider on April 10, 2021.