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

We decided that the Plan does not have to pre-approve an OmniSeq Comprehensive Panel.

You asked the Plan to pre-approve an OmniSeq Comprehensive Panel. You say that you have an appointment for this testing. You say that your doctor has advised that cancer has spread all over your body. The Plan denied your request. The Plan says the criteria for coverage of the requested genetic test have 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 an OmniSeq Comprehensive Panel. Our reviewer says that an OmniSeq Comprehensive Panel is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have a diagnosis of Malignant neoplasm of hypopharynx, unspecified. The enrollee has squamous cell carcinoma with metastases to the lung, mediastinum, liver, and brain. The enrollee does not have a diagnosis of non-small cell lung cancer or metastatic colorectal cancer.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an OmniSeq Comprehensive Panel have not been met. Therefore, we decided that the Plan does not have to pre-approve an OmniSeq Comprehensive Panel.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says skilled
services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

Continued SNF services were requested. 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 
continued services. Our physician reviewer found that the enrollee is at a maximal assist level for bed mobility 
and transfers, contact guard assist for eating, and total assist for toileting. He does not have documented skilled 
nursing needs. He does not have documented skilled therapy needs. He appears to have reached a plateau in 
function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration 
of his condition. The enrollee's care needs at this point are custodial.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device provided by an out of network (OON) provider.

You asked the Plan to pay for the CPAP device. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained prior to this service.

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 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 continuous positive airway pressure (CPAP) device provided by an out of network (OON) provider.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services.

You asked the Plan to pay for the SNF services. You say that the services provided to the enrollee are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require skilled nursing or therapy services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical epidural steroid injection.

You asked the Plan to pre-approve a cervical epidural steroid injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 a cervical epidural steroid injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic neck pain. The enrollee denies radicular pain, numbness or tingling in the upper extremities. The enrollee takes Flexeril and Tramadol for pain. The enrollee had trigger point injections and had 30% pain relief for two weeks. An MRI shows mild spinal stenosis and some foraminal stenosis. The documentation does not support evidence of an indication for a cervical epidural steroid injection.

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 cervical epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical epidural steroid injection.
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 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 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 was admitted to the hospital with COVID, hypoxic respiratory failure and pneumonia. The enrollee does not require complex wound care or vent weaning. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the scaling and root planing (D4342 x 4), and the inhalation of nitrous oxide (D9230).

You asked the Plan to reimburse the full amount for the scaling and root planing, and nitrous oxide. You say that you do not understand why you are not eligible for your full $1,000 reimbursement for dental. You say that you were referred to this provider for the services. You say that the office told you they were out of network. You say that a plan representative verified that periodontal work was covered. You also say that you followed the plan's instructions to receive the work on your gums. You also say that you are on a fixed income. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network providers can bill you for any amount over the MAC. The Plan also says that member liability is a contractual obligation under the plan and cannot be waived.

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, out of network providers may still bill you for any amount greater than the MAC payment made by the plan to the provider. This is a contractual obligation under the plan and cannot be waived. Therefore, we decided that the Plan does not have to reimburse the full amount for the scaling and root planing (D4342 x 4), and the inhalation of nitrous oxide (D9230).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that you need more help to regain strength. The Plan
denied your request. The Plan says that you do not have skilled nursing or therapy needs.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer
found that you are at a contact guard to minimal assist level for all mobility. There are ongoing impairments
with balance and strength. Seated and supine exercises were attempted to minimize pain. You do not have
documented skilled nursing needs. You do have documented skilled therapy needs. Daily skilled services are
required to establish a maintenance program and/or to prevent deterioration of your condition. Your care needs
at this point cannot be provided at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have been met. The Plan must continue coverage for the SNF
skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or
the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve a skilled
nursing facility (SNF) admission and services.

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 admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be safely met in a lower level of care, such as a skilled nursing facility or home with home health 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 in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of 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 syncope, acute kidney injury and urinary tract infection. Medical problems are stable. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a folding wheeled walker.

You asked the Plan to pre-approve the walker. You say that this is medically necessary, as you have a two story home, and you need a walker for downstairs and one for upstairs. The Plan denied your request. The Plan says this is considered duplicate equipment.

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 walker. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the E0143 folding wheeled walker is not medically necessary as it is not reasonable and necessary for treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment already available to a patient. You state that you already have a walker and need one for upstairs which would be considered a duplicate. The documentation also does not reveal a detailed neuromuscular exam or gait evaluation indicating a mobility deficit that requires the E0143 walker.

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 walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a folding wheeled walker.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the complete series x-ray (D0210).

You asked the Plan to pay for the dental services. You say that you were given the name of this dentist by your health plan. You also say that the provider called the dental plan and obtained approval for the services. The Plan denied your request. The Plan says the dentist in this case is out of network. The Plan says that if you receive services from an out of network dentist, you are responsible for all costs related to those services.

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, dental services that you receive out of network are not covered. The record shows that you called the health plan on the date of service and you provided the name of the dentist in this case. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the complete series x-ray (D0210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.

You asked the Plan to pre-approve the benefits. You say that this should be paid for. The Plan denied your request. The Plan says there is no documentation of any of the qualifying diagnoses.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

The provider has attested in the case file that you have none of the covered comorbidities and conditions that would indicate the requested additional benefits. Based on this information, we decided that Medicare rules for coverage of the benefits have not been met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says custodial care is not covered without a skilled service.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.

The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for home health aide services provided to the enrollee.