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

We decided that the Plan does not have to pre-approvethe insertion of interlaminar/interspinous process stabilization/distraction device (22869) and associated anesthesia (99152).You asked the Plan to pre-approvethe insertion of interlaminar/interspinous process stabilization/distraction device and associated anesthesia. You say that the services are medically 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 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 the insertion of interlaminar/interspinous process stabilization/distraction device and associated anesthesia. 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. Therefore, theservice is not medically reasonable and 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 insertion of interlaminar/interspinous process stabilization/distraction device and associated anesthesia have not been met.Therefore, we decided that the Plan does not have to pre-approvethe insertion of interlaminar/interspinous process stabilization/distraction device (22869) and associated anesthesia (99152).
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 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 you required moderate to maximum assistance with sit to stand. You required maximum assistance with activities of daily living and transfers. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that you require the intensity of an IRF stay with close physician or nursing supervision. While you may benefit and participate in additional therapy of physical therapy and occupational therapy, your functional status does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires close monitoring for signs of sepsis. The Plan denied your request. The Plan says the enrollee does not require a multidisciplinary team approach and coordinated program 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 Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee's current level of function is moderate assist with toilet hygiene, moderate assist with bathing, moderate assist with upper body dressing, maximal assist with lower body dressing, moderate assist with bed mobility, ambulating 60 feet with a rolling walker with moderate assist, and transferring with moderate assist. The enrollee is currently medically stable, and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While he may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 the enrollee would benefit from continued vent weaning and managing secretions. The Plan denied your request. The Plan says the enrollee's current needs are being met in the 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 LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include tracheostomy care with ventilator support, neurologic monitoring, surveillance laboratory studies, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions of tooth #'s 6, 7, 9, and 14 provided on September 3, 2019.
You asked the Plan to pay for the extractions of tooth #'s 6, 7, 9, and 14.. You say that you do not understand how the Plan will only pay for 2 extractions when it took 6 extractions in order to have an upper denture. The Plan denied your request. The Plan says the benefits for this service have been satisfied and the frequency limitation has been exceeded.
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. Therefore, we decided that the Plan does not have to pay for the extractions of tooth #'s 6, 7, 9, and 14 provided on September 3, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay forthe services (CPT 99291) provided on March 21, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says that this is a column one procedure to a previously paid column two procedure.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 forwardto us information regarding their decision to deny your request. Medicare rules say that hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient. In this case,the services in question were provided to the enrollee by a different provider/facility than the provider who rendered the emergency care. The plan has not provided documentation supporting the denial of the services in question, therefore the plan's denial cannot be substantiated.Therefore, we decided that the Plan has to pay forthe services (CPT 99291) provided on March 21, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 17, 2019 through August 19, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from August 17, 2019 through August 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 18, 2019 by out of network provider.You asked the Plan to pay for the CT Scan (74177). You say that the services rendered were medically necessary. The Plan denied your request. The Plan says the member does not have out-of-network benefits.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 onJuly 18, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional 30 minutes of critical care services (99292) provide on May 21, 2019.You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not include the time spent rendering critical care services.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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes. We find that CPT code 99292 is not supported in the record. Specifically, the record does not indicate the time spend rendering critical care services. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for an additional 30 minutes of critical care services (99292) provide on May 21, 2019.
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 the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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-approve long term acute care hospital (LTACH) 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for IRF care 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the member is requiring assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period. 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 pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code 99291) provided to the enrollee on May 20, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
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 99291 is not supported in the medical record. Specifically, Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported. The documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The documentation does not include the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. 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 critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code 99291) provided to the enrollee on May 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three porcelain or ceramic pontics and three porcelain or ceramic retainer crowns provided on August 21, 2019.
You asked the Plan to pay for the pontics and retainer crowns. You say that you fell and suffered substantial damage to your permanent bridge. You also say that you were referred to this dental school because of their work with oncology patients. The Plan denied your request. The Plan says these services are not covered by the Plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the three porcelain or ceramic pontics and three porcelain or ceramic retainer crowns provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99337) provided on August 14, 2019 by an out of network provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service August 14, 2019. You say when practitioners are called in to see a patient as an attending provider in an outpatient capacity, the medical necessity has been pre-established. The Plan denied your request. The Plan says the referring provider is a non-participating provider. The attending provider is a non-participating provider. The Plan did not authorize any services. The services are not considered urgent/emergent in nature.
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 a domiciliary or rest home visit (99337) provided on August 14, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the refractive state determination. We decided that the Plan does not have to waive the cost share for the office visit and eye exam.
You asked the Plan to waive the cost share for the office visit, eye exam and refractive state determination. You say that you were informed the provider was in-network. You say that the in-network rate should be paid. The Plan says that the cost share applied correctly.
We decided that the Plan has to waive the coinsurance for the refractive state determination.
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 clearly says that enrollees must pay a $55 copayment for out-of-network physician specialist services. The refractive state determination is considered a physician specialist service, which is included in the $55 office visit copayment. Therefore, we decided that the Plan has to waive the coinsurance for the refractive state determination.
We also decided that the Plan does not have to waive the cost share for the office visit and eye exam.
Your contract with the Plan clearly says that you must pay a $55 copayment for out-of-network physician specialist services and 40% coinsurance for out-of-network, non-Medicare covered routine eye exams. Therefore, we decided that the Plan does not have to waive the cost share for the office visit and eye exam.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health residential care services provided from October 14, 2018 to November 5, 2018.
You asked the Plan to pay for mental health residential care services. You say that these were medically necessary services. The Plan denied your request. The Plan says mental health residential care services are not a covered benefit under Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that Psychiatric Residential Treatment Facility means a facility, other than a hospital, that provides psychiatric services to individuals under age 21. We looked at the file and Medicare rules. The record shows that the enrollee was over the age of 21 for the dates of service at issue. Based on this information, we decided that Medicare rules for coverage of mental health residential care services have not been met. Therefore, we decided that the Plan does not have to pay for mental health residential care services provided from October 14, 2018 to November 5, 2018.