Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional vision services You asked the Plan to pre-approve the vision services. You say that the services are medically necessary.The Plan denied your request. The Plan says your vision benefits have been exhausted.The Plan must follow Medicare rules. The record shows your vision benefit with the plan has been exhausted. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pre-approve are considered routine vision services or eyewear.Therefore, we decided that the Plan does not have to pre-approveadditional vision services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 9, 2020 to January 12, 2020.
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied your request. The Plan says this was custodial care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF care. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found the records do not show that the enrollee had any identifiable skilled therapy service needs. While the enrollee needed therapy services, he did not require skilled therapy services on a daily basis. The enrolle also did not meet severity of illness or intensity of service criteria for 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 pay for skilled nursing facility (SNF) care provided from January 9, 2020 to January 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additions of a tooth to an existing partial denture (D5650 x2) provided on February 20, 2020. You asked the Plan to pay for the additions of a tooth to an existing partial denture. You say that you have been using dentures for 50 years, a few teeth fell off of the denture, and you needed it repaired. You also say that you are on a limited income and cannot afford to pay for this. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 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 pay for the two additions of a tooth to an existing partial denture (D5650 x2) provided on February 20, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the medical services provided from July 16, 2019 to August 29, 2019.
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has not provided any documentation showing that the enrollee was disenrolled
from Medicare. We find that the Plan has not substantiated their reasoning for denial per Medicare
criteria. Therefore, we decided that the Plan has to pay for the medical services provided from July 16, 2019 to
August 29, 2019.
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: 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 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee required maximum assistance with bed mobility. The enrollee required moderate assistance with grooming, toileting, lower and upper body dressing, and bathing. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status requires or can fully tolerate an 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 pay forinitial hospital care(CPT Code 99222) provided to the enrollee on February 15, 2020.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the Plan states per Medicare guidelines, the member's services should be billed under Original Medicare.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on February 14, 2020. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forinitial hospital care (CPT Code 99222) provided to the enrollee on February 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided from January 13, 2020 through January 23, 2020.
You asked the Plan to pay for SNF care. You say that the stay is not medically necessary. The Plan denied your request. The Plan says there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the stay was medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided from January 13, 2020 through January 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional services. You say that the enrollee would significantly benefit from the continuation of his care to reduce radicular symptoms. The Plan denied your request. The Plan says the enrollee is at his highest level of function.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional services. Our physician reviewer found that the requested therapy is not generally accepted effective therapy for the enrollee's condition. He has made some progress in therapy, but the records indicate he continues to have moderate levels of pain and mild functional activity limitations. The documentation does not support that he requires the unique skills of a professional therapist to safely and effectively provide treatment. The services do not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. The enrollee has had extensive therapy for his condition, and was trained in a home exercise program. He has a follow up with his physician as he now has radicular symptoms, and additional modifications to a treatment plan can be made at that time. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health skilled nursing visits.You asked the Plan to pre-approvehome health care. You say that you need to continue home care because you have an open wound but cannot go to the wound care center.The Plan denied your request. The Plan says the denial of authorization for the requested home health services is correct.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home health care. Our reviewer says that you do not meet the Medicare criteria for the requested home health care services. Our physician reviewer found the records do not show that skilled nursing services are required to effectively providetreatment, care, and/or services which are medically necessary for you beyond what was already approved by the Plan. Your wounds are healing, and the wound care is not complex. You do not need 7 additional visits with the skills of a professional nurse. You and your caregiver have had training on your condition and the training can be completed with the home health visits already authorized 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 home health care have not been met. Therefore, we decided that the Plan does not have to pre-approvehome health skilled nursing visits.
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 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 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 was admitted to the hospital for seizure, confusion, respiratory failure, sepsis, and UTI. Treatments have included mechanical ventilation, antiseizure medication, and IV antibiotics. The enrollee does not require services at the LTACH that are not already available at the current acute care hospital or a skilled nursing facility. There are no services available at the proposed LTACH that the enrollee requires that are not already available and covered at the current hospital 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 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a dental crown for tooth #4 (D2750).
You asked the Plan to pre-approve the crown. You say that the crown is medically necessary. The Plan denied your request. The Plan says that the root canal must be re-treated before a crown would be appropriate.
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. The Plan covers the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the crown is medically necessary. Our physician reviewer found placement of a crown on tooth #4 meets the criteria for coverage to restore the tooth to adequate function. Although the root canal fill does not reach the radiographic apex, there is no evidence of periapical pathology and the enrollee is asymptomatic. The retreatment of the root canal without any apparent symptoms would pose a greater risk of complication due to the presence of a post within the root. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-approve a dental crown for tooth #4 (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility care provided out of network.
You asked the Plan to pay for the out of network skilled nursing facility care. You say that the enrollee is a
resident of the facility and was seen by the provider in dispute upon the request of the facility. You say that no
other mental health providers will see these nursing home patients. You say that it is difficult for your providers
to say no, when ordered to see a patient. You say that the treatment in dispute was medically necessary. The
Plan denied your request. The Plan says there was not an approved prior authorization on file to cover the
services supplied by a non-plan provider. The Plan says that the enrollee was not covered for a skilled nursing
stay at the facility on the date of service in question.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for skilled nursing facility care provided out of network.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for genetic tests. You say that the treating physician ordered these tests in order to assist in determining the optimal treatment options for the enrollee. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network and prior authorization was not obtained or requested.
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 ordering provider is also out-of-network with the Plan. 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 medical services provided on August 15, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gralise ER tablet.
You asked the Plan to pre-approve Gralise ER (J8499). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition under the Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gralise ER tablet.
Benefits for Gralise ER (J8499) may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 requires daily physician
oversight, and monitoring of comorbidities. The Plan denied your request. The Plan says the enrollee is
expected to rapidly recover, and does not require at least 25 days 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 physician
reviewer found that you have a past medical history of stroke, encephalopathy, and diabetes. You were
admitted to the acute care hospital with respiratory failure requiring intubation, due to bilateral pulmonary
emboli. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general,
LTACHs do not provide clinical services that are materially different than those of short term acute care
hospitals. You are receiving acute hospital care, and acute care services have not been denied. The
documentation does not support that you require services at the LTACH that are not available at the acute care
hospital where you are currently receiving care. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and your condition 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after
June 21, 2020.
You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 continued SNF coverage. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found you received oral medications.
You had stable vital signs. You required stand-by assistance with bed mobility. You required maximum
assistance of two for transfers. You remained non-ambulatory. The documentation does not support that you
require the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to
safely and effectively provide medically necessary and reasonable treatment. The documentation does not
support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, you
no longer require the necessary services on an inpatient basis, at a SNF 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 continued SNF coverage have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) coverage after June 21, 2020.