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

We decided that the Plan does not have to pre-approve a skilled nursing facility admission.
You asked the Plan to pre-approve a skilled nursing facility admission. You say that SNF care is medically
necessary. The Plan denied your request. The Plan says the clinical information provided did not indicate that
the enrollee needs daily inpatient skilled nursing care or daily therapy services
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 a skilled nursing facility admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has no
skilled nursing needs. Functionally, she is totally dependent and unable to follow commands and participate in
therapy and hence does not require daily skilled therapy services on an inpatient basis in an SNF. Rehabilitation admissions need patients to be able and willing to participate with clear cut functional goals. This enrollee is not meeting these expectations and is more appropriate for hospice care given her condition. A SNF admission is not medically necessary and she is at the level of hospice 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 a skilled nursing facility admission have not been met. Therefore, we decided
that the Plan does not have to pre-approve a skilled nursing facility admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the unlisted molecular pathology procedure (81479) provided on February 13, 2021.

You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for molecular or predisposition genetic testing. 

The enrollee has been asked to pay $700 (Plan allowed amount of $3,500 x 20% coinsurance) for the genetic laboratory testing provided.

This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when she enrolled in the Plan. Therefore, we decided that the Plan does not have to adjust the coinsurance for the unlisted molecular pathology procedure (81479) provided on February 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5214).

You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that [Enter appellant's argument from appeal letter, e.g. "...you need SNF care."] The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.

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, complete maxillary denture (D5110) and mandibular partial denture (D5214) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and mandibular partial denture (D5214) on May 9, 2019 and your complete maxillary denture (D5110) and mandibular partial denture (D5214) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5214).
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 an IRF admission is medically necessary. The Plan denied your request. The Plan says an IRF 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 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 pneumonia and acute respiratory failure. The enrollee's medical problems 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, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF services.
You asked the Plan to pre-approve continuation of SNF services. You say that the enrollee needs more rehabilitation as he is not ready to go home. The Plan denied your request. The Plan says continuation of SNF services is 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 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 continuation of SNF services. Our
reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based
on review of the available records, the enrollee does not meet the CMS coverage criteria for continued
coverage at the skilled nursing facility. The enrollee is medically stable. The enrollee has no skilled nursing
needs. Functionally, he is at a standby assist level for mobility, which does not require daily skilled therapy
services on an inpatient basis in an SNF. Continued coverage at the skilled nursing facility is not medically
necessary and is not supported by documentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the
Plan does not have to pre-approve continuation of SNF services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve 10 physical therapy visits. You say that the records provided support the 
need for physical therapy services. The Plan denied your request. The Plan says the enrollee can continue 
treatment with a home program. The Plan says that more skilled treatment is not needed at this time. 
 
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 10 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee has previously been treated with outpatient 
therapies and should be independent with a home exercise program.  There is no documentation of a recent 
injury or decline in function. The additional therapy services are not an appropriate duration and frequency for 
treatment of the enrollee's medical condition and therefore are not 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 10 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 10 physical therapy visits.
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 disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for surgical repair of a hip fracture after a fall. She is now medically stable with no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided from July 27, 2020, to July 29, 2020.
You asked the Plan to pay for the skilled nursing facility services. You say that you received a bill for these 2 days that the enrollee was at the facility while waiting for their coronavirus test results to come back. The Plan denied your request. The Plan says there were no skilled service provided on the dates of service in this case.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there were no identifiable skilled nursing service needs. There were no identifiable skilled therapy service needs. The beneficiary did not require skilled nursing or therapy services on a daily basis. This beneficiary 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 the skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided from July 27, 2020, to July 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
the SNF admission is medically necessary. The Plan denied your request. The Plan says the member's clinical 
condition does not require skilled nursing care as an inpatient. 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  The 
enrollee's care needs, as a practical matter, can be provided 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection between a wheelchair controller and power seating system motors (E2311).

You asked the Plan to pre-approve the electronic connection. You say that this power wheelchair and related accessories are medically necessary for this enrollee. The Plan denied your request. The Plan says this requested item is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories can be covered when they 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 electronic connection. Our reviewer says that the requested electronic controller connection is not medically necessary. Our physician reviewer found that based on the medical records provided, there is no documentation that there a medical need for the enrollee to control the power options through the joystick. Records indicate the enrollee is independent with eating, thus indicating the enrollee has adequate upper extremity function to control the power options with their own switches. 

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 electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between a wheelchair controller and power seating system motors (E2311).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 21, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 21,
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (36247) provided July 1, 2019.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 36247 is selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity branch, within a vascular family. We find that CPT code 36247 is not supported in the medical record. Specifically, the medical records submitted do not include documentation of a selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity branch, within a vascular family.
Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (36247) provided July 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a porcelain crown (D6750), retainer crown (D6740), and core buildup (D2950) for the enrollee. 

You asked the Plan to provide coverage for these dental services. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says the requested services were not coded correctly to allow coverage on the prior authorization. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that MAXIMUS determined the Plan had to pre-approve a porcelain crown (D6750) for teeth #s 18 and 20, as well as a core buildup (D2950) on tooth #20. The Plan states the crowns on teeth #s 18 and 20 are integral components to a 3-unit fixed bridge, called retainer crowns, which enables replacement of a missing tooth. In this case, the missing tooth is #19, which was surgically extracted by the treating dentist. The Plan states the fixed bridge component that replaces a missing tooth is called a pontic, not a retainer crown. The dentist submitting the claim for the fixed bridge submitted code D6740 (retainer crown) for the missing tooth or pontic. This is an incorrect code and an appropriate reason for denial. The appropriate code in this instance is D6240 (pontic - porcelain fused to high noble metal). The Plan states a predetermination of benefits cannot be accurately processed when a retainer crown code is submitted as a replacement for a missing tooth. The appropriate pontic code (D6240 is this case) must be submitted. A D6750 code will be automatically rejected and denied by the dental claim system.

The Plan further states that dental claim systems are highly dependent on submission of the appropriate and correct codes. These systems do not permit claims personnel to make coding or tooth number changes to claims when incorrect information is submitted. To do so would violate the integrity of the claims process. Additionally, the American Dental Association (ADA) has fought hard to prohibit such practices by dental insurance companies. The provider must submit a claim on the enrollee's behalf that is accurate and coded correctly.

The Plan is correct in this case. 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 primary issue here was the pre-determination was submitted with in appropriate codes and therefore could not automatically be approved by the Plan in accordance with the dental benefit and the dental coding rules. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D6750), retainer crown (D6740), and core buildup (D2950) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 3, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

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. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services for the enrollee.