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

We decided that the Plan does not have to pay forthe post stabilization inpatient care provided to the enrollee from November 26, 2019 to November 27, 2019.You asked the Plan to pay forthe post stabilization inpatient care. You say that these services were medically necessary.The Plan denied your request. The Plan says that the enrollee's medical condition was stabilized on 11/23/2019 prior to admission.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post stabilization inpatient care. Our reviewer says that the post stabilization inpatient care was not medically reasonable and necessary for the enrollee in this case. The enrollee was evaluated in the Emergency Department on 11/23/19 for altered mental status, nausea and vomiting. After evaluation was completed, the Emergency Department physician documented that she was stable and made plans to admit for observation for altered mental status, vomiting, fecal retention and elevated lactic acid. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. Based on the clinical documentation available in the medical record, the patient stable to transfer by ambulance to an in-network hospital at 3:37 PM on 11/23/19, after completion of the Emergency Department evaluation. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for the post stabilization inpatient 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 the post stabilization inpatient care have not been met.Therefore, we decided that the Plan does not have to pay forthe post stabilization inpatient care provided to the enrollee from November 26, 2019 to November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to approve in-network cost sharing for the cataract to be provided by an
out of network (OON) provider.
You asked the Plan to approve in-network cost sharing for the OON cataract surgery. You say that you cannot
afford to pay the OON cost sharing and there is no in-network retinal specialist who can treat you. The Plan
denied your request. The Plan says there are multiple in-network eye surgeons who can perform this cataract
surgery. If you wish to go OON, you must use your OON benefits and cost sharing.
Medicare rules say that plans can require enrollees to get care from network providers in order to get the innetwork
cost sharing rates.
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. You state that there are no in-network
retinal specialists; however, we have confirmed that the requested provider is not a retinal specialist. We found
no exception that would require the Plan to approve in-network cost sharing for these items/services. Therefore,
we decided that the Plan does not have to approve in-network cost sharing for the cataract to be provided by an
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power scooter.You asked the Plan to pre-approvethe scooter. You say that you have had falls and currently your hands and shoulders are broken and you cannot walk due to a broken foot.The Plan denied your request. The Plan says you have been provided with other mobility equipment and you have not been evaluated recently to determine whether or not these meet your needs in the home setting. Without an evaluation for this, the scooter cannot be approved.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you have not been evaluated by physical therapy to determine whether a power wheelchair is needed to help with MRADLs in the home. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea power scooter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care from March 1, 2020 through
March 27, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you do not understand how the facility
is charging this amount since it should be $150 per day, and it not equally what it should cost. The Plan denied
your request. The Plan says you had met $1255.92 of their total out of pocket maximum and was charged for
the difference.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
According to your 2020 EOC, you must pay $0.00 for days 1 through 20, and $150.00 for days 21 through 100.
You were in-patient the facility for 35 days. This means, you would owe $2250.00 for the 15 days over the first
20 that have a zero copay. However, when the claim processed, you had met $1255.92 out of the $3000.00 out -
of-pocket (OOP) maximum. Therefore, only $1744.08 was applied as the copayment. The claim has processed
correctly, and the out-of-pocket maximum has been met. 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 SNF care from March 1, 2020 through March 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient hospital care is
medically necessary. The Plan denied your request. The Plan says that the documentation pre-operatively does
not meet the threshold for an intensity of services or underlying member hemodynamic instability that could
only be managed in an acute inpatient setting.
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 pre-approve acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. The enrollee is undergoing a total knee replacement with a diagnosis of osteoarthritis. Medical history
also includes obstructive sleep apnea and fibromyalgia. The reviewed documentation does not include medical
records or rationale for the requested inpatient services. The scheduled procedure is not on the inpatient only
list. Without the support of the documentation, medical necessity for inpatient services are not supported. Our
physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital
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 acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care for the enrollee.
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 reconsideration because the LTACH admission is not medically necessary. The Plan denied your request. The Plan says the enrollee can receive all necessary hospital care in the current 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the member does not have specific indication for LTACH placement. There are no needs that will be offered by the LTACH that are not available at current level of care. The member does not have rehab capability that would be consistent with necessitating LTACH placement. 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 records provided support the need for IRF care.
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have 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 enrollee suffered a stroke. On July 18, 2020, the enrollee had mild expressive
aphasia and right UR and LE drift. The enrollee's blood pressure was moderately well controlled on July 22,
2020. It is documented that the enrollee and his family wish to go home and have intense outpatient rehab
rather than inpatient. The enrollee was working with physical therapy. he documentation does not support that
the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee is medically stable at this time and does not have
complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehabilitation
physician three times per week. While he may well benefit from continuing physical therapy and occupational
therapy, the documentation does not support that there is 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 21, 2020 by a nonparticipating
provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says they reviewed your contact history and have no
record of a provider verification call from you prior to services being rendered.
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.
Review of the file show that you received dental services on January 21, 2020 by a non-participating provider.
Your EOC states, enrollees must pay 100% for out-of-network dental services. 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 dental services provided on January 21, 2020 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on November 7, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.
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.
You exhausted your $1,000 maximum benefit allowance because the plan paid the $1,000 to previous claims
and you are liable for the rest of the costs. Therefore, we decided that the Plan does not have to pay for the
dental services provided on November 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe SNF admission. You say that the enrollee requires daily skilled services in the SNF setting.The Plandenied your request. The Plansaysthe enrollee's needs are mostly custodial and less than daily skilled services would be adequate.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 correctin denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care due to acute respiratory failure and left sided colitis with rectal bleeding. The hospital course has included abdominal pains, and sustained episodes of ventricular tachycardia (most recently on 7/19/2020 with no symptoms). The enrollee is now hemodynamically stable, and able to make needs known. There is no fever, significant anemia, and/or signs of toxicity.The enrollee is now mostly standby assist for all care. He has no complex wound care needs or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser 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 the SNF admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant 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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at an alternate 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 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 pre-approve continued skilled nursing facility (SNF) care beyond July 22, 2020.You asked the Plan to pre-approve the SNF care. You say that you were only the in SNF for three days when this denial was issued. You believe you need more daily therapy to regain function.The Plan denied your request. The Plan says you do not require daily skilled services.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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 85 year old male with perforated duodenal ulcer who underwent laparotomy and was admitted to the SNF. From a nursing perspective, the beneficiary received oral and inhaled medications. The beneficiary had stable vital signs. His lungs were clear. He had routine chronic urostomy care. He was treated for pain with effect. Regarding rehabilitation services, the beneficiary received PT and OT in the SNF. By the dates in question, the beneficiary was at a moderate to maximal assist level with functional mobility including gait to a few feet. The beneficiary required varying assist with ADLs. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, this is not required on a daily basis. This beneficiary does 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 the SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond July 22, 2020
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe inpatient hospital care provided to the enrollee from 11:43 AM on September 29, 2019 to September 30, 2019.You asked the Plan to pay forthe inpatient hospital care. You say that the enrollee was not stable for transfer.The Plan denied your request. The Plan says that that the enrollee was stable.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient hospital care. Our reviewer says that the inpatient hospital care was medically reasonable and necessary for the enrollee in this case. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. Based on the clinical documentation available in the medical record, the patient was stable to transfer by ambulance to an in-network hospital on 9/30/19 at 11:50 PM. On 9/29/19, the patient had been recently weaned from Levophed but had documented need over the last 24 hours for intermittent respiratory support in the form of BiPaP, for which he had required Precedex for sedation. His respiratory status was stable at the time of examination but given documented need for recent interventions, he was not clearly stable for discharge on this day. Ourphysician reviewer found that the enrollee's condition met Medicare criteria for inpatient hospital 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 inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe inpatient hospital care provided to the enrollee from 11:43 AM on September 29, 2019 to September 30, 2019.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.