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

We decided that the Plan does not have to pre-approve inpatient admission for this procedure.
You asked the Plan to pre-approve coverage for inpatient admission for this procedure. You say that inpatient
admission is necessary. The Plan denied your request. The Plan says while the procedure itself is approved, the
enrollee can be place in observation status and can be converted to inpatient after the procedure if it is
medically necessary.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for inpatient care. 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 provide coverage for inpatient admission. Our reviewer says that the
documentation does not support that the criteria for inpatient care are met in this case. Our physician reviewer
found the enrollee is a 66-year-old who has been directed to have a diverticulectomy of the hypopharynx with
or without myotomy, cervical approach. Inpatient Admission status has been requested but not justified. There
was no evidence of lack of control of these conditions or of any other comorbidity or other risk factor which
might raise the risk of this surgical procedure to justify at least a two-midnight stay in the hospital following
the procedure. We looked at this physician's review, the file, and the Medicare rules. Based on this
information, we decided that Medicare rules for coverage of inpatient admission are not met at this time.
Therefore, we decided that the Plan does not have to pre-approve inpatient admission at this time.
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 enrollee should not return home. The Plan denied your request. The Plan says the services the enrollee needs could be provided in another setting.
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 the records do not show that the enrollee has any identifiable skilled nursing or therapy service needs. The enrollee also 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee's current needs appear not to be skilled in nature.
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 that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee has no acute medical needs, and no complex rehab needs.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee is at minimal assist for sitting up, ambulating using a rolling walker, and toilet transfers. She is at moderate to maximum assist for upper and lower body dressing. 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. 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 forthe vision care provided on December 9, 2019.You asked the Plan to pay forthe vision care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. You were seen by the provider on December 9, 2019 for a vision visit. Per your health plan benefit you are covered for subsequent vision visits with a $50.00 copayment responsibility. The records indicate you had your initial vision visit in on April 17, 2019.Therefore, we decided that the Plan does not have to pay for the vision care provided on December 9, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the
requested admission to a SNF.
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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee is diagnosed with
cerebral vascular accident, pneumonia and COVID-19. From a nursing perspective, the enrollee received oral
and ophthalmic medications. The enrollee had stable vital signs. Her lungs were clear. Her appetite was fair.
Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute
hospital. The enrollee was at a supervision to touch assist level with functional mobility including gait. The
enrollee required varying assist with activities of daily living.
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee 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 admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper and lower dentures.
You asked the Plan to pre-approve the requested dentures. You say that your dentures went missing at the hospital. The Plan denied your request. The Plan says dentures are a benefit once every 5 years.
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.
We looked at the file, and Medicare rules. The documentation provided shows that the requested services were last received on December 7, 2016. Your plan only covers dentures once every 5 years. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve complete upper and lower dentures.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services.You asked the Plan to pre-approve out of network physician services. You say that these services are medically necessary.The Plan denied your request. The Plan says this provider is not 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 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 out of network physician services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says the care you
need can be provided to you with a doctor in the 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 OON services. Therefore, we decided that the Plan does not have to pre-approve
medical services to be 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 IRF 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 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 complexity your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not currently require intensive physician and nursing oversight in an IRF.There were no significant post-operative complications. The documentation does not support that you require or can participate in an intensive rehabilitation therapy program provided in an IRF.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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care admission.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient admission is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated in observation.
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. Our physician reviewer found the record does not show that the admitting physician reasonably expects that the patient's necessary hospital care will span two midnights. The supplied clinical does not indicate the presence or expectations for severe perioperative acute complications. If the member undergoes the procedure and intra- or post-operatively requires care that meets an inpatient level of services, then the Plan would approve inpatient care as an observation conversion. 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 the acute inpatient hospital care admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve speech therapy services.
You asked the Plan to pre-approve speech therapy. You say that you are appealing. The Plan denied your
request. The Plan says the denial of authorization for speech therapy is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 speech therapy. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the requested therapy is not generally accepted as specific and
effective therapy for the enrollee's condition. The documentation reveals no cognitive linguistic deficits that
require speech therapy. The records do not reveal any deficits that require the unique skills of a professional
speech therapist to safely and effective provide treatment, or that services can be safely and effectively
performed only by a therapy, or under the supervision of a therapist. The requested services are not part of a
maintenance program and the specialized skill, knowledge, and judgment of a qualified therapy is not require
to establish, design, or deliver a program to maintain your current condition or to prevent/slow further
deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of speech therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve speech therapy services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography testing with test code 95810.
You asked the Plan to pre-approve polysomnography. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Plan already approved polysomnography with test code 95811 and thus the additional requested code of 95810 is redundant.
The Plan follows Medicare rules. Medicare rules say that polysomnography tests are covered by Medicare for certain conditions when medically necessary. 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 polysomnography. Our reviewer says that the enrollee does not meet the Medicare criteria for coverage of the additional requested polysomnography test. Our physician reviewer found the enrollee does meet the criteria for a sleep study as they were previously diagnosed with sleep apnea and needed recalibration of continuous positive airway pressure (CPAP) device settings as it had been more than 8 years since the last study. However, the Plan already approved polysomnography with test code 95811, which includes all of the additional requested code 95810 as well as continuous positive airway pressure therapy or bilevel ventilation, which already covers everything the enrollee would need. Performing test code 95810 in addition to 95811 would be redundant, and there is no clinical indication for this. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography testing with test code 95810.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the EKG and laboratory work provided
from February 3, 2020 to February 4, 2020.
You asked the Plan to waive the copayments for the EKG and the laboratory work. You say that you are
appealing your portion of the Medicare approved amounts for procedures, tests and lab work. You say
normally pay for 20% of approved plan cost but now are you paying the total amount. The Plan denied your
request. The Plan says you have been charged the correct cost sharing 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 $95
copayment for in-network diagnostic procedures and tests performed by a provider other than your primary
care physician and a $20 copayment for in-network laboratory services performed by a provider other than
your primary care physician.
You have been asked to pay a $95 copayment for the EKG and a $20 copayment for the laboratory work. The
EKG and the laboratory work fall 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 copayments for the EKG and laboratory work provided from February 3,
2020 to February 4, 2020.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact
the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve unlisted evaluation and management service identified with code 99499.
You asked the Plan to pre-approve unlisted evaluation and management service. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are identified by a different code.
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 99499 is unlisted evaluation and management service. We find that CPT code 99499 is not supported in the medical record. Specifically, review of the file shows that you are requesting an office visit with an out of network provider. The code needed for the requested telehealth visit is identified with code 99212, not 99499. Based on this information, we decided that Medicare rules for coverage of unlisted evaluation and management service have not been met. Therefore, we decided that the Plan does not have to pre-approve unlisted evaluation and management service identified with code 99499.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Retacrit (epoetin alfa). You asked the Plan to pre-approve Retacrit. You say that your bone marrow cannot produce much blood, and you need this procedure to sustain your blood. The Plan denied your request. The Plan says the denial of authorization for Retacrit is correct, because Retacrit is not medically necessary for you. The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Retacrit. Our reviewer says that you do not meet the Medicare criteria for the requested Retacrit. Our physician reviewer found based on the records provided there is no indication of chronic kidney disease, myelodysplastic syndrome, recent myelosuppressive chemotherapy, human immunodeficiency virus (HIV) infection, or planned upcoming surgery. The requested epoetin alfa is not medically reasonable and necessary for you. The documentation does not support that epoetin alfa would be safe and effective for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Retacrit (epoetin alfa).