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

We decided that the Plan does not have to pay for specimen handling (99000) provided on November 5, 2019.
You asked the Plan to pay for specimen handling. You say that this was a medically necessary service. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that a specimen collection fee will not be paid to anyone who has not extracted the specimen. We looked at the file and Medicare rules. The record does not show that the specimen was extracted by the billed rendering provider. Based on this information, we decided that Medicare rules for coverage of specimen handling have not been met. Therefore, we decided that the Plan does not have to pay for specimen handling (99000) provided on November 5, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health care provided to the enrollee on September 14,2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan 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 foroutpatient mental health care provided to the enrollee on September 14,2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for emergency room services provided to the enrollee on two separate instances for the same date of service, February 2, 2020.
You asked the Plan to pay for the emergency room services provided to the enrollee on February 2, 2020. You say that the enrollee had two separate visits to the emergency room on the same date. You provided medical records to show two separate visits. The Plan denied your request. The Plan says that this claim was partially paid.
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 sent an incomplete case file and did not fully explain its partial approval. The records provided show two separate visits to the emergency room on the same day by the enrollee. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for emergency room services provided to the enrollee on two separate instances for the same date of service, February 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, the enrollee does not require daily skilled nursing or daily skilled therapy services at a SNF 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 not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex).You asked the Plan to pre-approveinsertion of an interspinous spacer device. You say that the enrollee's pain would be relieved with Vertiflex.The Plan denied your request. The Plan says this service has not been proven to be clinically effective.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 todetermine if the Plan was correct in denying the request to pre-approve insertion of an interspinous spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device 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 insertion of an interspinous spacer device have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital discharge day management; more than 30 minutes (99239) provided May 22, 2020.You asked the Plan to pay forcode 99239. You say that the billed services are supported by the medical records.The Plan denied your request. The Plan says the billed code is 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.We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not document discharge day management of more than 30 minutes. Based on this information, we decided that Medicare rules for coverage of code 99239 have not been met. Therefore, we decided that the Plan does not have to pay forhospital discharge day management; more than 30 minutes (99239) provided May 22, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on May 8, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plandenied your request. The Plan says theenrollee received services within the last three years by a provider within the same group practice with the same specialty. An established evaluation and management code should have been used.The servicing provideron the submitted claim has a specialty of internal medicine per the National Provider Identifier (NPI) registry.The claim included a group name of Physician Referral Services, the tax id and a taxonomy code. Review of the claim history shows a paid claim, including code 99215, for another provider of the same group on January 29, 2019. Therefore, a new patient code cannot be billed. 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, this claim cannot be paid as billed based on the type of claim submitted and the provider group. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on May 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approveSNF services. You say that SNF admission is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with  the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF.  The enrollee does not have complex wound care or other ongoing SNF level SN need. The enrollee's functional level  does not require  skilled therapy services withthe specialized skill, knowledge and judgment of a qualified therapist  to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination ofthese services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that IRF admission is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not 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 thecomplexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documentation of a need for an intensive rehabilitation program.There is not a reasonable expectation that this enrolleewill be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nucynta.
You asked the Plan to pre-approve Nucynta. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nucynta.
Benefits for Nucynta may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided to the enrollee from January 5, 2020, to March 8, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that inpatient care was medically necessary for the enrollee.The Plan denied your request. The Plan says that the recordsprovided do not support Medicare criteria for inpatient admission were met.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. Based on the medical records provided, the admitting physician indicated that further care for the enrollee was required. The enrollee was ultimately treated for cellulitis and required extensive care. We find the documentation supports that the criteria for inpatient payment are met in this case. Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided to the enrollee from January 5, 2020 to March 8, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen 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-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF admission is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not 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 thedocumentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.The documentation does not support that the enrollee requires atleast 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days, of therapy services.Medicare coverage criteria are not met. 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 pre-approve insertion of an intrauterine device (IUD).
You asked the Plan to pre-approve the IUD. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Plan rules state that contraception is not covered.
The requested service is not considered medically necessary by either Medicare or the plan. Based on this
information, we decided that Medicare rules for coverage of the IUD have not been met. Therefore, we decided
that the Plan does not have to pre-approve insertion of an intrauterine device (IUD).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveuse of Gelsyn-3.You asked the Plan to pre-approveGelsyn-3. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee had a previous injection on June 5, 2020,but there are no notes of how often this drug was used, the clinical effect of the drug, the enrollee's functional status, whether they have had non-operative treatments, or what the effectiveness of previous injections were.The Plan follows Medicare rules. Medicare rules say that repeat administration of Gelsyn-3 is only covered under certain indications.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 Gelsyn-3. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested repeat injection of Gelsyn-3. Our physician reviewer found there is no documented information on the clinical results of the prior 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 Gelsyn-3 have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of Gelsyn-3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown - porcelain fused to predominantly base metal (D2751) and the core buildup (D2950).
You asked the Plan to pre-approve the porcelain crown and core buildup. You say that the services are medically necessary for the enrollee. The Plan denied your request. The Plan says the core buildup is not a covered services and you have exhausted your benefit limit for crown 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. The Plan covers 2 crowns per calendar year. We looked at the file, and Medicare rules. The file indicates that in March 2020, you received 2 crowns which exhausted your benefit limit. Therefore, no additional crowns would be covered for the calendar year. Though the Plan offers a dental benefit in excess of Medicare coverage, the crown buildup service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the crown - porcelain fused to predominantly base metal (D2751) and the core buildup (D2950).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not support that skilled therapy services and skilled nursing services are medically reasonable and necessary on a daily basis. Medicare coverage criteria are not met. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission.You asked the Plan to pre-approveSNF care. You say that SNF admission is medically necessary.The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of SNF care.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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found your functional leveldoes not requireskilled therapy services with the specialized skill, knowledge and judgment of a qualified therapisttosafely and effectively provide medically necessary and reasonable treatment. You do not require skilled nursing or skilled therapy services on a daily basis in a SNF. As a practical matter, you do not require the necessary services on an inpatientbasis, 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-approveskilled nursing facility (SNF) admission.