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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care.

Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 pre-approve several surgical tooth extractions (coded as reconstruction of the jaw (21248)), which you would like to be covered under the medical portion of the Plan.

You asked the Plan to pre-approve the dental care. You say that your teeth are rotting, and several dental providers have told you that they require surgical removal because they are breaking. You are in a great deal of pain, and request that these services be covered under the medical portion of your plan. The Plan denied your request. The Plan says Original Medicare does not cover dental services, which are defined as services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. The requested services are dental. These services cannot be covered under the medical portion of your plan. However, some of the services requested may qualify for coverage under your supplemental dental benefits. You can get more information about your dental benefits by contacting the Plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage.

The services requested are excluded from Medicare coverage. However, the Plan offers a supplemental dental benefit. The requested services may be covered under the dental portion of the Plan. Therefore, we decided that the Plan does not have to pre-approve several surgical tooth extractions (coded as reconstruction of the jaw (21248)) under the medical portion of the Plan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on January 11, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on January 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient psychiatric hospitalization provided on August 14, 2020, through November 21, 2020.

You asked the Plan to pay for inpatient psychiatric hospitalization. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric hospitalization. Our reviewer says that the service is not medically necessary. Our physician reviewer found it was not expected this enrollee would improve in a reasonable period of time. This patient did not show any abnormal behaviors or any symptoms which would require acute treatment nor was she shown to be a danger to herself or others. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospitalization have not been met. Specifically, medically necessary services could have been provided at a lower level of care. This means that the inpatient psychiatric hospitalization after August 13, 2020 was not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric hospitalization provided on August 14, 2020, through November 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction and 3 fillings provided from December 10, 2020, to January 19, 2021.

You asked the Plan to pay for the extraction. You say that a plan representative advised you should pay for the services you received in 2020 out of pocket and then submit the claim for reimbursement. You say that you cannot afford to do that as you are on disability. You say that you were advised by the dental office prior to your appointment that they were in network for 2021. You also say that the provider was listed as in network on the Dental Plan's website. The Plan denied your request. The Plan says the provider in this case was out of network on the date of service. The Plan says that the call records do not support that you, nor the office contacted the Plan to verify provider network status prior to the date of service. The Plan also says that dental services performed out of network are not covered.

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 and extraction is listed as covered, dental services performed out of network are not among those covered under this benefit. The record shows that the provider's network status changed to in network on January 27, 2021. Therefore, we decided that the Plan does not have to pay for the extraction and 3 fillings provided from December 10, 2020, to January 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical and imaging services rendered on January 20, 2021.

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 procedure codes 76937 and 36000 are not supported.

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 76937 is ultrasonic guidance for blood vessel access
((List separately in addition to code for primary procedure).

We find that CPT code 76937 is not supported in the medical record. Specifically, given that the primary procedure code 36000 is not payable, the add-on code is also not payable. Based on this information, we decided that Medicare rules for coverage of these services have not been met.

The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.

Billed procedure code 36000 (introduction of needle or intracatheter, vein) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the surgical and imaging services rendered on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you do not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. 

We looked at the file and Medicare rules. The records show that you do not inject insulin more than three times per day. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 you no longer require skilled 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.

Continued SNF services beyond June 17, 2021, 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 from a nursing perspective, you received oral medications, had stable vital signs, and were treated for an uncomplicated wound. There are no identifiable skilled nursing service needs. Regarding rehab services, by the date in question, you required contact guard assist with transfers. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. 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 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 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the initial hospital care (99223) provided on January 30, 2021.

You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because the services were urgent and emergent and eligible for payment. The Plan denied your request. The Plan says that the member was not inpatient status on the billed date of service.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan's denial in this case is neither valid nor supported with evidence. The record indicates that the member was discharged from another hospital and admitted to the billing facility on January 30, 2021. The fact that the member was an outpatient in another facility on this same date is irrelevant to the issue of the Place of Service code for these services. There is no indication that the member was in an observation level of care with the billing facility on January 30, 2021. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the initial hospital care (99223) provided on January 30, 2021.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network provider.

You asked the Plan to pre-approve out-of-network dialysis services. You say that you were not aware you could not go to this provider due to a plan change. The Plan denied your request. The Plan says the services can be provided by a contracted dialysis 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies for maintenance of non-insulin drug infusion catheter coded A4221 and the infusion supplies for external drug infusion pump coded A4222 provided on July 25, 2020 to July 31, 2020.

You asked the Plan to pay for the supplies for maintenance of non-insulin drug infusion catheter and the infusion supplies for external drug infusion pump. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not supported by the documentation.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation does not include an itemized shipping/billing invoice to indicate the specific supplies provided or a proof of delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the supplies for maintenance of non-insulin drug infusion catheter coded A4221 and the infusion supplies for external drug infusion pump coded A4222 provided on July 25, 2020 to July 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211).

You asked the Plan to pre-approve the maxillary partial denture. You say that you lost your top partial. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

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, maxillary partial denture (D5211) is limited to one procedure every five plan years. The record shows that you received a maxillary partial denture (D5211) on March 21, 2019 and your maxillary partial denture (D5211) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5211).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.

You asked the Plan to pre-approve a CPAP device. You say that this item is medically necessary. The Plan denied your request. The Plan says there is no physician order for the required services.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid physician order. In this case, there is no physician order for the requested CPAP device. It is noted that you are yet to have a sleep study performed so the criteria for coverage have also not been satisfied. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal intraoral x-rays provided on February 8, 2021.

You asked the Plan to pay for the occlusal intraoral x-rays. You say that you did not know you needed to be seen by a participating provider. The Plan denied your request. The Plan says this service is not covered.

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. Bitewing x-rays and panoramic x-rays are the only x-rays covered under the Plan. Therefore, we decided that the Plan does not have to pay for the occlusal intraoral x-rays provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmic diagnostic imaging provided on
February 15, 2021.

You asked the Plan to waive the copayment for ophthalmic diagnostic imaging. You say that you disagree with
being charged a second copayment and feel that the test should be included as part of the eye exam. 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 $50
copayment for each diagnostic procedure or test.

You have been asked to pay the allowed amount of $41.33, which is less than the $50 copayment for
ophthalmic diagnostic imaging. Ophthalmic diagnostic imaging falls within the outpatient diagnostic tests and
therapeutic services and supplies 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 for
ophthalmic diagnostic imaging provided on February 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The
Plan denied your request. The Plan says rules for LTACH care have 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 that the enrollee is a 79-year-old female with a history of hypertension and
pulmonary fibrosis/interstitial lung disease who came to the hospital June 2, 2021, after passing out, with low
blood oxygen levels, shortness of breath, and cough. In this case, there is no documentation provided
necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care
hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital
where she 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. The requested LTACH services
are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and
able to be furnished safely and effectively only on an inpatient basis.

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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve urogynecologist services to be provided by an out of network provider.

You asked the Plan to pre-approve urogynecologist services. You say that this doctor was recommended to you and you feel this doctor can help you. The Plan denied your request. The Plan says services are available to you in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve urogynecologist services to be provided by an out of network provider.