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

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 24, 2019 through December 20, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were released after the colonoscopy surgery and had to return to the hospital the same night. You state you feel that you should not have any responsibility due since you had to return to the hospital. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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 admitted on November 24, 2019 and discharged on December 20, 2019. You were asked to pay a $295 copayment per day from November 24, 2019 through November 29, 2019, days 1-6 of your inpatient stay. There were no copayment charges from November 30, 2019, day 7 of your inpatient hospital care until your day of discharge December 20, 2019. Per your contract there is a $295 copayment per day required for days 1-6. 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 inpatient hospital care from November 24, 2019 through December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flexible protective outer surface covering system for a
below the knee endoskeletal system (CPT L5962).
You asked the Plan to pre-approve the protective outer cover for a below the knee prosthesis. You say that the
information supplied by your providers supports your request in this case. The Plan denied your request. The
Plan says there is no documentation to support the requested item is medically necessary.
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 does not serve a purpose that is primarily medical in nature. Specifically, the
records show that the plan has approved a custom shaped protective cover below the knee (L5704). The records
show that the item in dispute is being requested for cosmetic reasons, because it resembles skin. There is no
evidence that the item in dispute is being requested to address a medical need that is not already being met by
the items approved by the Plan. Therefore, we decided that the Plan does not have to pre-approve a flexible
protective outer surface covering system for a below the knee endoskeletal system (CPT L5962).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the spine (72128). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found the enrollee is reported to have a compression fracture of T12 level after a fall. Documentation notes the enrollee had plain film imaging completed in the emergency department on the day of the fall and had a follow-up consultation with neurosurgery. It is unclear from the submitted documentation why a thoracic CT spine is currently requested. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the spine (72128).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950) and endodontic therapy (D3330) on tooth #18.
You asked the Plan to pre-approve core buildup and endodontic therapy on tooth #18. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup (D2950) and endodontic therapy (D3330) on tooth #18.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiology services provided on February 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for cardiology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for cardiology services provided on February 12, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for should elbow wrist hand orthosis (L3960) provided to the
enrollee on January 7, 2020.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the orthosis have not been met. The documentation submitted did
not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot
be verified. Therefore, we decided that the Plan does not have to pay for should elbow wrist hand orthosis
(L3960) provided to the enrollee on January 7, 2020.
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. The Plan denied your request. The Plan says the enrollee has no acute medical needs that require intensive rehab.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee suffered a stroke with seizures and encephalopathy. The enrollee's vital signs are normal. She is following simple commands. Dilantin is being administered, and the enrollee has not had clinical seizures since admission. The enrollee is generally medically stable. The documentation does not support that she has complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehab physician three times per week. While the enrollee will likely benefit from continuing physical and occupational therapy, the documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 provide coverage for coverage for additional routine transportation.
You asked the Plan to provide coverage for additional routine transportation. You say that additional
transportation is necessary. The Plan denied your request. The Plan says once this benefit is exhausted it cannot
be extended.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 36 one-way trips per year. We looked at your request, the records in the
case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum
benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide
coverage for coverage for additional routine transportation.
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 you are a fall risk and needs more intense therapy. The Plan denied your request. The Plan says you do not require frequent physician management, or an interdisciplinary approach to rehab 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 above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that you were admitted to the hospital with right leg pain and swelling. You are generally medically stable. The documentation does not support that you have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehab physician three times per week. While you are expected to benefit from continuing physical and occupational therapy, the documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: 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 is unsafe to be at home, and needs to
regain strength. The Plan denied your request. The Plan says the enrollee does not need frequent physician
management, or an interdisciplinary approach for rehab 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 above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that the enrollee was hospitalized with for a stroke in June, 2020. She requires minimal to moderate assistance
for transfers, personal care, and ambulation, and has limited activity tolerance due to the paralysis of her left
side. The enrollee's medical condition has stabilized. The documentation does not support that she has complex
medical issues that require acute rehab nursing care, or monitoring by an inpatient rehab physician three times
per week. While the enrollee may benefit from continuing physical and occupational therapy, the
documentation does not support that there is need for an intensive therapy program with therapy 3 hours per
day, with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: 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 rehab will teach you how to walk with prosthetics.
The Plan denied your request. The Plan says you do not have medical complexities to require regular daily
provider visits.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that you were admitted to the hospital with an infected diabetic ulcer of the left foot. You underwent a left
below-knee amputation. Your medical condition has stabilized. The documentation does not support that you
have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehab
physician three times per week. While you are expected to benefit from continuing physical and occupational
therapy, the documentation does not support that there is need for an intensive therapy program with therapy 3
hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from care in
the LTACH setting. The Plan denied your request. The Plan says the enrollee is still requiring debridements
and would likely need readmission for further procedures if transferred to LTACH.
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 the enrollee is a male with a past medical history of spastic paraplegia, end stage
renal disease, neurogenic bowel and a stage IV sacral decubitus ulcer who presented to the acute hospital on
07/03/2020 with altered mental status due to polymicrobial sepsis. He was treated in the hospital with
intravenous antibiotics and surgical wound debridement. Other hospital issues included acute hypoxic
respiratory failure, urinary tract infection, hypoglycemia, a right internal jugular vein thrombosis, anemia,
encephalopathy and need for hemodialysis. He is to continue intravenous antibiotics through 08/14/2020. He is
on Eliquis for the venous thrombosis. He continues dialysis three times per week. His hemoglobin is being
monitored - he was transfused on 07/22/2020. His last wound debridement was on 07/16/2020. Transfer to a
long-term acute care hospital is requested.
The short-term acute care hospital can provide for all the patient's present inpatient care needs and the patient is
receiving an appropriate level of care in the present setting. Continued care in the short -term acute care hospital
is appropriate until the patient is stable to transfer to 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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on February 25, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the 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 medical services provided to the enrollee by an out-of-network provider
on February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on November 1, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for lab services provided on November 1, 2019 by an
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on February 10, 2020. You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition. The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on February 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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.