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

We decided that the Plan does not have to pay for the services (A9270) provided to you on September 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "N" under the Physician Fee
Schedule indicates that the code in question is non-covered.
We looked at the file and Medicare rules. Code A9270 is assigned a status indicator of "N" under the Physician
Fee Schedule, which means that this code is not covered. Based on this information, we decided that Medicare
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay
for the services (A9270) provided to you on September 2, 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 an IRF admission is medically necessary. The Plan denied your request. The Plan says The enrollee can safely receive the services needed in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy. Under Medicare, the request 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable. There are no complex nursing or rehabilitation needs. 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. 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 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. 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 naturopathic services you received from September 15, 2020, to November 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says services provided by a naturopath are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for the naturopathic services you received from September 15, 2020, to November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-network provider on March 2, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 services provided by an out-network provider on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided by an out-of-network provider on January 13, 2021.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided by an out-of-network provider on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this item is
medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage
have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to preapprove
a therapeutic continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3310) for tooth # 7.
You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied your request. The Plan says root canal is listed as a non-covered service.
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 root canal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3310) for tooth # 7.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on January 18, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid because Medicare rules state that the codes used are valid for Covid 19 testing. The Plan denied your request. The Plan says it was unable to confirm that you are CLIA certified by Medicare and therefore you are not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. Providers must also be eligible to accept Medicare Payment.
In this case, Maximus has confirmed that the providers CLIA number does not show active on the government website. We were unable to confirm the provider was an eligible provide at the time of service. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device.
You asked the Plan to pre-approve MyoPro Motion G Orthotic device. You say that you feel this device is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for the requested device.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 MyoPro Motion G Orthotic device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have left hemiparesis as a result of a stroke in August 2018. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Therefore, you do not meet criteria for the requested device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MyoPro Motion G Orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours a day /5 day a week, or 15 hours over 7 consecutive days, of therapy 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 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 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 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 for weakness and facial droop and was diagnosed with supranuclear palsy. 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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

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 there are no complex nursing or rehabilitation needs. The enrollee does need physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.

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. Specifically, medically necessary services can be provided in a lower level of care. This means that admission into an IRF is not medically necessary. 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 you need wound care. The Plan denied your request. The Plan says your 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 physician reviewer found that you were admitted to the acute hospital for fever, a non-healing wound, bacteremia, and sepsis. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Therefore, the requested LTACH services 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 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen by an out-of-network (OON) provider.
You asked the Plan to pre-approve a CT scan of the abdomen. You say that this service is medically necessary. The Plan denied your request. The Plan says that they have in-network providers available to provide for the enrollee's medical needs.
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. In this case, the Plan has acknowledged that the requested CT scan is medically necessary. They are only objecting to it being performed by an OON provider. We needed more information that provided examples of some in-network providers that would be able to provide for the enrollee's needs. A response to this request was not received. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen by an out-of-network (OON) provider.
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 an IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee can safely receive the services needed in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy. Under Medicare, the request 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable. There are no complex nursing or rehabilitation needs. 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. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiovascular specialist visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve cardiovascular services. You say that you need to see a cardiovascular specialist due to your condition. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network cardiovascular specialist.
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 a cardiovascular specialist visit to be provided by an out of network (OON) provider.