Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fifteen (15) skilled nursing visits, eight (8) PT visits and 8 OT visits.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.
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 the services. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration beyond what was approved by the health plan.
Your conditions are chronic and stable. There is no complex wound care. You have been instructed in disease management. The records do not show that skilled therapy (physical therapy or occupational therapy) services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration beyond what was approved by the plan. You have been instructed on safety and a home exercise program. Your functional level does not require ongoing skilled PT or OT beyond what was already approved. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve fifteen (15) skilled nursing visits, eight (8) PT visits and 8 OT visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81223, 81302, 81330, 81345, 81404,
81405, 81406, 81407, 81408, 81479) provided on May 1, 2020.
You asked the Plan to pay for laboratory services. You say that this was requested by the physician. The Plan
denied your request. The Plan says this was a screening service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, laboratory services, was requested solely for screening purposes. Medicare does
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for
laboratory services (81223, 81302, 81330, 81345, 81404, 81405, 81406, 81407, 81408, 81479) provided on
May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea trial of a spinal cord stimulator (SCS).You asked the Plan to pre-approvethe SCS trial. You say that it is felt that this should be allowed to help with his pain.The Plan denied your request. The Plan says the enrollee's mild stenosis is not an accepted indication for SCS.The Plan follows Medicare rules. Medicare rules say that SCS may be covered for treatment of intractable pain due to one of the above listed conditions.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 SCS trial. Our reviewer says that the documentation does not support that the Medicare criteria are met. Our physician reviewer found the enrollee is a male with chronic neck pain, for which he takes tizanidine and pregabalin. The Progress notes also state that he has tried and failed PT, Heat/ Ice, Massage, stretching and rest. He had a psychological evaluation and is cleared. His MRI shows spinal stenosis and foraminal stenosis. He had facet joint injectionswithout pain improvement. There is no documentation of a cervical epidural steroid injections, TENS or other physical medicine modalities.The patient does not have an evidence-based indication for an SCS trial.The patient has not had clearly documented conservative measures and has not had a multi-disciplinary approach to his pain management.The requested procedure is not medically reasonable or 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 SCS trial have not been met.Therefore, we decided that the Plan does not have to pre-approvea trial of a spinal cord stimulator (SCS).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for laboratory services (80061, 82306, 83036) provided on June 14, 2019, to January 11, 2020.
You asked the Plan to hold you harmless for laboratory services. You say that your provider said these tests were medically necessary. The Plan denied your request. The Plan says that these tests do not meet Medicare guidelines.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. The laboratory services at issue were provided by a contract provider. The file does not show that the Plan provided notice that laboratory services would not be covered. Under Medicare rules, this means laboratory services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for laboratory services (80061, 82306, 83036) provided on June 14, 2019, to January 11, 2020.
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 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 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 preapprove
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 based on the documentation provided,
the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an
IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative
services with regular physician evaluation. The enrollee's care needs can be met 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 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-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF 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 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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient staywith an interdisciplinary approach to rehabilitation care. You were admitted for syncope. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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-approveacute 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 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 based on the documentation provided, the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. Your care needs can be met 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 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 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 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 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 pneumonia and congestive heart failure. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvepercutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650 x2).You asked the Plan to pre-approvethe DME. You say that the DME is necessary.The Plan denied your request. The Plan says that the diagnostic indications required for approval were not documented in the medical history included with this request 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 DME. Our physician reviewer found in this case, the member was noted to have a history of chronic low back pain. The pain can be/has been attributed to the lumbar spine and is the result of a nerve root injury (compression). The member was evaluated by neurosurgery who did not feel that the member was an adequate surgical candidate. The member had otherwise previously hadtreatment with PT, ESIs and pharmacotherapy. They were cleared by a psychologist for the requested service. In this setting, the member would meet/satisfy the requirements of the NCD/LCD for coverage of a SCS trial.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 DME have been met.Therefore, we decided that the Plan has to pre-approvepercutaneous implantation of neurostimulator electrode array, epidural(CPT Code 63650 x2).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for breast tomosynthesis (77061) provided on May 12, 2020.
You asked the Plan to pay for breast tomosynthesis. You say that this is supported in the records. The Plan denied your request. The Plan says this is not a valid code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 77061 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for breast tomosynthesis (77061) provided on May 12, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless forlaboratory testing provided on June 17, 2020.You asked the Plan to hold you harmless forlab testing. You say that your provider ordered these tests as preventive services so you should not be responsible for these charges.The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing does not meet the Medicare coverage criteria.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.This testing was performed by an in-network provider. The file does not show that the Plan provided notice that lab testing would not be covered. Under Medicare rules, this means lab testing is considered approved by the Plan.Therefore, we decided that the Plan has to hold you harmless forlaboratory testing provided on June 17, 2020.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 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 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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a blood clot associated with dialysis fistula and was treated for a gallbladder infection. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home visit (99342) and nail plate removal (11730) provided on March 6, 2020 by an out of network (OON) provider.You asked the Plan to pay forhome visit and nail plate removal. You say that the services rendered were medically necessary.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergentservices rendered by an out-of-network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan didnot 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 forthe home visit (99342) and nail plate removal (11730) provided on March 6, 2020 by an out of network (OON) provide
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.You asked the Plan to pre-approvethe compression stockings. You say that the stockings are needed for treatment.The Plan denied your request. The Plan says Medicare will not pay for the compression stock because they are wound care items which are non-covered underthe surgical dressing benefit because they do not meet the statutory definition of a dressing.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6530
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364) provided on September 1, 2020.
You asked the Plan to pay for cone beam CT. You say that the service was medically necessary. The Plan denied your request. The Plan says the service rendered is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, CDT code D0364 is not listed in the Plan's Dental Evidence of Coverage. Therefore, we decided that the Plan does not have to pay for cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364) provided on September 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 22, 2019,, an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that You did not provide an argument in your appeal request.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. The Plan says that neither the ordering provider nor the provider of service is a Plan provider.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 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 topay forthe medical services provided on April 22, 2019, by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency care provided on May 22, 2020.You asked the Plan to waive the copayment foremergency care. You say that you were discharged to soon and had to be readmitted within 15 minutes.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foremergency care provided on May 22, 2020.