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

We decided that the Plan does not have to pre-approve the admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that IRF care is medically necessary for the enrollee's condition. 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 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 while skilled nursing services and skilled therapy services are medically necessary for the enrollee's condition, the enrollee is receiving appropriate care in the current inpatient rehabilitation facility. The enrollee is weak and deconditioned and is working with physical, occupational and speech therapy in the inpatient rehabilitation facility. He is requiring assistance with mobility, transfers and activities of daily living. In this case, SNF care cannot be considered until the enrollee is stable for transfer. 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 the admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation (93293) rendered by the out of network (OON) provider on February 1, 2021.
You asked the Plan to pay 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 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation (93293) rendered by the out of network (OON) provider on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on January 18, 2021, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided to the enrollee on January 18, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) monthly supplies provided on March 4, 2021.
You asked the Plan to pay for the TENS supplies. You say that this is medically necessary and should be paid. The Plan denied your request. The Plan says the diagnosis codes billed for this claim are not valid.
The Plan must follow Medicare rules. Medicare rules say that for diagnosis codes that indicate laterality, unspecified side codes should be used when the medical record does not identify the side of the condition.
In this case, the claim reports diagnosis codes for pain in the right knee, left knee, and unspecified knee. The records clearly indicate bilateral knee pain. As such, it is not appropriate to report the code for unspecified side. Based on this information, we find that the Medicare billing rules are not met in this case. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) monthly supplies provided on March 4, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003) provided on November 25, 2020.
You asked the Plan to pay for the infectious agent detection. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003) provided on November 25, 2020.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for right leg weakness and was
managed without surgery for stenosis of L5-S1. Medical conditions are stable. There are no complex nursing or
rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. The enrollee 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.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy provided on September 3, 2020.
You asked the Plan to pay for the medical nutrition therapy. You say that you would like reconsideration because the services provided were medically necessary. The Plan denied your request. The Plan says no clinical information was submitted.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services
only for enrollees with renal disease or diabetes.
We looked at your request, the file and Medicare rules. Based on this information, we have determined that
Medicare coverage criteria have not been met. Specifically, the record does not include any clinical
documentation. There is insufficient documentation to determine if coverage criteria have been met in this case.
Therefore, we decided that the Plan does not have to pay for medical nutrition therapy provided on September
3, 2020.
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 reasonable and 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 the patient was admitted to an acute care hospital for hip pain after recent hip
replacement surgery. He had revision hip arthroplasty. 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 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 the patient was admitted to an acute care hospital for metabolic encephalopathy, C
difficile colitis and a urinary tract infection. 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 IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for knee pain after recent knee replacement surgery. 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. 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 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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the 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 There is no documentation provided necessitating admission to an 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 she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete denture-mandibular (CPT code D5120) and complete denture-maxillary (CPT code D5110).
You asked the Plan to pre-approve the dental services. You say that you do not know how long it has been since you were able to chew a piece of meat properly due to horrible work the dentist had done. The Plan denied your request. The Plan says you exhausted your 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. Review of the file shows that you exhausted your benefit because you received complete denture-maxillary and complete denture- mandibular on January 17, 2020. Your 2021 EOC states, "services include: Complete dentures (upper and lower) (One (1) upper complete and one lower complete denture every five (5) years, including routine post-delivery care) or Partial dentures (upper and lower) (One upper and/or one lower partial denture every five years, including routine post-delivery care)." Therefore, we decided that the Plan does not
have to pre-approve complete denture-mandibular (CPT code D5120) and complete denture-maxillary (CPT code D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212) x-ray spine, lumbosacral (72100) xray
spine, cervical, two or three views (72040) provided from February 5, 2021, to February 8, 2021.

You asked the Plan to pay for the chiropractic services. You say that in order to have chiropractic sessions you
are required to undergo x-rays by your health care provider. Please see by the enclosed report that this was
necessary. You wish to have it paid as you could not have services otherwise. The Plan denied your request.
The Plan says these services are not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the office visit (99212) x-ray spine, lumbosacral (72100) x-ray spine, cervical,
two or three views (72040) provided from February 5, 2021, to February 8, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room (ER) visits you had on March 6, 2021, and March 7, 2021.

You asked the Plan to waive the copayments for the ER visits. You say that you don't think you should have to pay these copayments because they were related to the Coronavirus (COVID-19). The Plan denied your request. The Plan says you were charged these copayments correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for each emergency room visit.

Records show that you went to the ER on March 6, 2021 because you had a reaction to the COVID-19 vaccine. You then returned to the ER on the following day because you had a case of hives. You have been asked to pay a $65 copayment for each of the ER visits. This means that you have been asked to pay the correct amount based on your contract with the Plan. There is no provision in your contract for a waiver of these amounts if the services are related to COVID-19. 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 copayments for the emergency room (ER) visits you had on March 6, 2021, and March 7, 2021.
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 services are 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-approvethe LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient therapy sessions to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve outpatient therapy sessions. You say that you have a complex mental health issue and believe this provider will be helpful. The Plan denied your request. The Plan says they have in-network providers available to provide for your medical needs.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve outpatient therapy sessions to be provided by an out of network (OON) provider.