Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 you were admitted for nonoperative management of a sacral fracture after a fall. Your medical conditions are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. Your care needs can be met 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 11, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics.
The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on September 11, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 11,
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been
met.

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 that 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 the enrollee 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 Plan.

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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational
therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable
expectation that the 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for a medical eye exam with photographs (92014, 92250)
provided on October 23, 2020.
You asked the Plan to hold you harmless for a medical eye exam with photographs. You say that you looked at
the Plan's online provider directory and saw the provider at issue listed as in-network. The Plan denied your
request. The Plan says that the provider at issue is not contracted with the Plan for medical services, there was
no authorization on file, no referring provider, and no misinformation given by the Plan.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
Plans have a responsibility to ensure that contracting physicians and providers know whether specific items and
services are covered in the Plan in which their patients are enrolled. If a network physician furnishes a service
or directs a beneficiary to another provider to receive a Plan-covered service without following the Plan's
internal procedures (such as obtaining the appropriate Plan pre-authorization), then the beneficiary should not
be penalized to the extent the physician did not follow Plan rules. The Plan follows these rules.
You received a medical eye exam with photographs by a Plan contract provider. The file does not show that the
Plan provided notice that the services at issue would not be covered. The Plan provider did not follow the
Plan's internal procedures for obtaining prior authorization. Though this provider does not appear to be
contracted by the Plan for both routine and medical vision services, you could not have reasonably believed
these services would not be covered. The Plan provider has a responsibility to know what services are covered
under the Plan and you should not be penalized according to Medicare rules. This means a medical eye exam
with photographs is considered approved by the Plan. Therefore, we decided that the Plan has to hold you
harmless for a medical eye exam with photographs (92014, 92250) provided by a Plan provider on October 23,
2020.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two custom fabricated abutments, two abutment
supported porcelain fused to metal crowns, first intraoral periapical x-ray, and additional intraoral periapical x-ray
provided on January 17, 2020.
You asked the Plan to pay for the custom fabricated abutments, abutment supported porcelain fused to metal
crowns, and intraoral periapical x-rays. You say that you believe these services should be covered. The Plan
denied your request. The Plan says the custom fabricated abutments and abutment supported porcelain fused to
metal crowns are not covered services. The Plan also says that your intraoral periapical x-rays benefit has been
satisfied and the frequency limitation has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the custom fabricated abutment and
abutment supported porcelain fused to metal crown are not among those covered under this benefit. The Plan
contract says that intraoral x-rays are limited to one procedure per calendar year. The record shows that you
received an intraoral x-ray on January 15, 2020, and your intraoral x-rays benefit has been exhausted. The
record also shows that you contacted the Plan prior to this date of service and asked about crowns, but did not
indicate that the crowns would be on implants, which are not covered. Therefore, we decided that the Plan does
not have to pay for the two custom fabricated abutments, two abutment supported porcelain fused to metal
crowns, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on January 17, 2020.
Your complaint about your frustration with the Plan is not a valid appeal for medical coverage. This part of
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is the most appropriate level of care for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 that 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 the enrollee 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 Plan.
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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites, prophylaxis, periodic oral evaluation, and bite wings provided from November 17, 2020, to December 28, 2020 by an OON provider.

You asked the Plan to pay for the resin-based composites, prophylaxis, periodic oral evaluation, and bite wings. You say that you were not aware that this provider was no longer in-network with your plan. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that the OON provider is allowed to bill you the difference between their billed amount and the allowed amount.

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, you are responsible for a $100 deductible, plus the difference between the billed amount and the allowed amount. Therefore, we decided that the Plan does not have to pay for the two resin-based composites, prophylaxis, periodic oral evaluation, and bite wings provided from November 17, 2020, to December 28, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the miscellaneous supply or accessory for use with an implanted ventricular assist device coded Q0508
You asked the Plan to pay for the miscellaneous supply or accessory for use with an implanted ventricular assist device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code Q0508 is miscellaneous supply or accessory for use with an implanted ventricular assist device.
We find that CPT code Q0508 is not supported in the medical record. Specifically, these services were billed without a required modifier. Based on this information, we decided that Medicare rules for coverage of the miscellaneous supply or accessory for use with an implanted ventricular assist device have not been met. Therefore, we decided that the Plan does not have to pay for the miscellaneous supply or accessory for use with an implanted ventricular assist device coded Q0508
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 SNF is recommended due to decline in physical
functional mobility. 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 the enrollee does not have daily skilled
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on
an inpatient basis in a Skilled Nursing Facility (SNF) setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests, problem focused limited oral evaluation, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on March 15, 2021.
You asked the Plan to pay for the pulp vitality tests, problem focused limited oral evaluation, and intraoral periapical x-rays. You say that you were advised that almost all procedures are covered up to a $2,000 allowance. The Plan denied your request. The Plan says the pulp vitality tests are not a covered service. The Plan also says that your benefits for the problem focused limited oral evaluation and intraoral periapical x-rays have been satisfied and the frequency limitations have been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the pulp vitality tests are not among those covered under this benefit. The contract says that periodic oral exams and emergency diagnostic exams are limited to two procedure codes per calendar year. The record shows that you received problem focused limited oral evaluations on January 21, 2021, and January 25, 2021, and your periodic oral exams and emergency diagnostic exams benefit has been exhausted. The Plan contract also includes intraoral x-rays as a covered benefit and are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray on January 21, 2021, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the pulp vitality tests, problem focused limited oral evaluation, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on March 15, 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.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 that the patient was admitted for non-surgical management of a hip fracture. 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. In conclusion, 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care following your surgery is medically necessary. The Plan denied your request. The Plan says the criteria for inpatient hospital care have not been met in this case.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnight. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnight or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is undergoing a planned total knee arthroplasty. She is medically stable and has been provided medical clearance to undergo this elective procedure. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnight.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide continuous glucose monitoring (CGM) sensors (K0553). You asked the Plan to provide CGM sensors (K0553). You say that you tried a CGM and it has effectively and efficiently allowed you to maintain your glucose levels. The Plan denied your request. The Plan says you do not meet criteria for a CGM.
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 you do not use insulin with at least
three daily injections nor 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 CGM sensors (K0553) have not been met. Therefore, we decided that the Plan does not have to provide continuous glucose monitoring (CGM) sensors (K0553).