Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that your needs can continue to be provided at a lower level of care.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 Medicarerules 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 11, 2020 by a nonparticipating
provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-participating 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 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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on March 11, 2020
by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on July 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.
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 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 lab tests provided on July 15, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 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 enrollee does not meet criteria for IRF admission. Our physician reviewer found this enrollee is now status post left groin washout for a seroma and abscess collection, on 7/15/2020. A wound VAC and local wound care is ongoing. Now, vitals are stable. The enrollee is hemodynamically stable, but does have worsening anemia and a Hemoglobin below 8. Functionally, the enrollee is mostly minimal assist/supervised for care. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly minimal/standby assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. Periodic labs can be performed at a lesser level.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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve residential mental health treatment.
You asked the Plan to pre-approve residential mental health treatment. 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. Medicare rules say that Medicare payment can only be made to providers
that are enrolled in the Medicare program. Inpatient psychiatric care can be covered when reasonable and
necessary only when provided by a hospital that meets certain requirements in order to enroll as an inpatient
psychiatric facility.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of residential mental health treatment have not been met. In this case, the facility requested does not
meet the requirements to be enrolled in Medicare as an inpatient psychiatric facility and, as such, is not
enrolled in Medicare. Although these services may be appropriate, Medicare payment cannot be made for the
services rendered in this facility. Therefore, we decided that the Plan does not have to pre-approve residential
mental health treatment.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for esophagoscopy, flexible, transoral; diagnostic, including
collection of specimen(s) by brushing or washing, when performed (separate procedure) (43200) provided
October 29, 2019.
You asked the Plan to pay for the esophagoscopy. You say that the records provided should support the
necessity of the services. The Plan denied your request. The Plan says the medical records do not support
billing the 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.
In this case, the CPT Code Manual definition of code 43200 is esophagoscopy, flexible, transoral; diagnostic,
including collection of specimen(s) by brushing or washing, when performed (separate procedure.
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 esophagoscopy. Our reviewer says that
based on the records received the criteria for billing or reimbursement consideration has not been met. Our
physician reviewer found the medical records provided do not include documentation of an esophagoscopy,
flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed
(separate procedure) being performed on October 29, 2019, therefore this service cannot be verified.
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 esophagoscopy have not been met. Therefore, we decided that the Plan does
not have to pay for esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by
brushing or washing, when performed (separate procedure) (43200) provided October 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional logisticare mileage (A0170).
You asked the Plan to pre-approve additional logisticare mileage. You say that the additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. Therefore, coverage criteria has not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 one-way transportation trips per calendar year when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional logisticare mileage (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Freestyle Libre Sensor and Reader.You asked the Plan to pre-approvea Freestyle Libre Sensor and Reader. You say that the items are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is met.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 Freestyle Libre Sensor and Reader. Our reviewer says that the items are notmedically necessary. Our physician reviewer found the criteria requires that the enrollee has diabetes mellitus and uses insulin. The enrollee does not appear to have diabetes mellitus and does not use insulin. In addition, we are not told why the enrollee could not use a glucometer to check his blood glucose levels and investigate glucose patterns that way. 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 Freestyle Libre Sensor and Reader have not been met.Therefore, we decided that the Plan does not have to pre-approvea Freestyle Libre Sensor and Reader.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastric bypass surgery (43644) and the associated hospital inpatient admission.You asked the Plan to pre-approve gastric bypass surgery and the associated hospital inpatient admission. 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 Medicare will cover bariatric surgery for enrollees who have: (1) a body mass index (BMI) of greater than or equal to 35; (2) at least one co-morbidity related to obesity; and(3) been unsuccessful with medical treatment for obesity.  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 gastric bypass surgery and the associated hospital inpatient admission. Our reviewer says that the services are not medically necessary. Our physician reviewer found your BMI is less than 35 kg/m2 and therefore none of the other criteria are applicable. You do not meet CMS criteria for bariatric surgery at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gastric bypass surgery and the associated hospital inpatient admission have not been met.Therefore, we decided that the Plan does not have to pre-approve gastric bypass surgery (43644) and the associated hospital inpatient admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve reinstatement of eyeglass benefit.
You asked the Plan to pre-approve reinstatement of eyeglass benefit. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says you exhausted your benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of reinstatement of eyeglass benefit have not been met. You exhausted your benefit because you had services on February 27, 2020. Your EOC states, "$400 each year - plan coverage limit for eyewear not covered by Medicare (but covered by the plan). If the vision item(s) you buy cost more than what the plan covers, you will pay the difference." Therefore, we decided that the Plan does not have to pre-approve reinstatement of eyeglass benefit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional extractions provided on January 16, 2020.
You asked the Plan to pay for the two additional extractions. You say that your teeth hurt, and the dentist told
you that you needed them removed because of a bacterial infection. You also say that this was a medical
condition and a health problem, and you need help paying for this. The Plan denied your request. The Plan says
your plan only covers two extractions per calendar year, which have already been approved for payment. The
Plan also says that they are unable to approve your request for payment of the additional dental extractions.
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, extractions are limited to two
procedures per calendar year. The record shows that you received four extractions on January 16, 2020, two of
which were covered by the Plan, and your extractions benefit has been exhausted. Therefore, we decided that
the Plan does not have to pay for the two additional extractions provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased March 14, 2020.You asked the Plan to pay for the hearing aids. You say that you had called the plan and was told that you were covered. You were never told about TruHeairng. You wanted good hearing aids and you are happy with what you bought and you feel this should be covered.The Plan denied your request. The Plan says hearing aids are limited to TruHearing branded hearing aid sand you must see a TruHearing provider to use this benefit.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from a TruHearing provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay for the hearing aids purchased March 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.The Plan must follow Medicare rules. The rules saythat LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require services at the proposed LTACH that are not already available at the current acute care hospital including weaning from ventilation support when fevers have resolved. Based on the provided documentation, it is unlikely the enrollee will require at least 25 additional days of acute care services. There are no services available at the proposed LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considerednot medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveaninterlaminar/interspinous device.You asked the Plan to pre-approveaninterlaminar/interspinous device. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 aninterlaminar/interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of aninterlaminar/interspinous device have not been met.Therefore, we decided that the Plan does not have to pre-approvean interlaminar/interspinous device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a past medical
history of hypertension, chronic kidney disease, arthritis, anemia, recent Clostridium difficile colitis and
diverticulitis who presented to the acute hospital on 07/24/2020 with weakness and requiring more care than
the family could provide. She had just been discharged from a skilled nursing facility to her home on
07/23/2020. She was evaluated and treated in the hospital. She is weak and deconditioned and has been
evaluated by physical and occupational therapy. She is walking 5 feet with a rolling walker with moderate
assistance and is moderate to maximum assist for transfers and activities of daily living. She is confused and
frail but medically stable.
Based on the medical records provided this enrollee does not require skilled nursing services, i.e., the
specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively
provide medically necessary and reasonable treatment. Based on the medical records provided this enrollee
does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist
required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical
records provided daily skilled services are not required. Based on the medical records provided this enrollee
does not require the services on 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 admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SNF stay provided from December 5, 2019 to December 7, 2019.You asked the Plan to waive the copayment forthe SNF stay. Yousay that you should have been discharged on the 20th day of your SNF stay. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $0 copayment per day for days 1-20 for covered in-network SNF stay and a $172 copayment per day for days 21-100 at an in-network SNF stay. You have been asked to pay a $516 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. The record shows you were discharged on December 8, 2019. See chart below.Dates of ServiceServiceCopayment per DaySNF DaysNumber of DaysMember LiabilityNovember 15, 2019 to November 30, 2019SNF care$01-1616$0December 1, 2019 to December 4, 2019SNF care$017-204$0December 5, 2019 to December 7, 2020SNF care$17221-233$516Total$516 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 forthe SNF stay provided from December 5, 2019 to December 7, 2019.