Persius/hicric huggingface dataset:
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 an IRF admission is medically necessary. The Plan denied your request. The Plan says IRF care is not medically necessary according to Medicare guidance since the member does not require complex therapy, close doctor monitoring and close nursing care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical
conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies provided during inpatient care provided to the enrollee from August 4, 2020, to September 14, 2020.
You asked the Plan to pay for this claim. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says per Current Procedural Terminology ("CPT") and Centers for Medicare and Medicaid Service ("CMS") guidelines, the cost of heparin flushes, saline flushes, IV flushes of any type, and solutions required to dilute or administer substances, drugs, or medications are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to inconsistent billing of supplies that are typically bundled into the facility payment and are not separately paid. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for supplies provided during inpatient care provided to the enrollee from August 4, 2020, to September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on March 29, 2021.
You asked the Plan to pay for services not related to manual manipulation. You say that you were in pain and needed treatment. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says any services billed other than manual manipulation by a chiropractor are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services provided on March 29, 2021.
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 the requested device. You say that you still have trouble staying asleep at night. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that positive airway pressure devices are only covered under certain medical indications.

We looked at the file and Medicare rules. The records provided do not show adherence to use of the device. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on August 24, 2020.

You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not separately payable.

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, we have confirmed that code 99232 for the subsequent hospital care services have a bundled relationship with code 99233 billed by another provider in the same tax identification group and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on August 24, 2020.
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 an LTACH admission and services are medically necessary for this enrollee. The Plan denied your request. The Plan says the enrollee is receiving the appropriate care in the current setting, and an LTACH would provide no clinical advantage. Therefore, the requested LTACH services are not medically necessary. Once the enrollee is stable and no longer requires an acute level of care, the necessary services can be provided in a different 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 that the enrollee is currently receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. Therefore, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to restore the benefit for a complete upper denture (D5110), and a complete lower denture (D5120) received on August 27, 2020.
You asked the Plan to restore the benefit for a complete upper denture, and a complete lower denture. You say that the dentures you received were not done correctly. Your mouth was hurting from the dentures and they did not fit. The Plan denied your request. The Plan says they are unable to restore the denture benefits.
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 your request, the file, and Medicare rules. Based on this information, we decided that the Plan's benefit for the complete upper denture and complete lower denture has been exhausted. Specifically, the record indicates that you received a complete upper denture and complete lower denture on August 27, 2020. The complete dentures were paid for accordingly by the Plan and the benefit cannot be restored. Therefore, we decided that the Plan does not have to restore the benefit for a complete upper denture (D5110), and a complete lower denture (D5120) received on August 27, 2020.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on February 22, 2021 to February 24, 2021.
You asked the Plan to pay for the compression stockings. You say that you need the stockings for lymphedema. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on February 22, 2021 to February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown (D6750), core buildups (D2950), a crown (D2750), and pontic (D6240).
You asked the Plan to pre-approve a retainer crown, core buildups, a crown, and pontic. You say that you want the Plan to cover these services. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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. Therefore, we decided that the Plan does not have to pre-approve a retainer crown (D6750), core buildups (D2950), a crown (D2750), and pontic (D6240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Life2000 system.

You asked the Plan to pre-approve Life2000 system. You say that this request is medically necessary. The Plan denied your request. The Plan says ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy will be denied.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 Life2000 system. Our reviewer says that the requested equipment is not medically reasonable and necessary. Our physician reviewer found This patient has COPD. However, there is inadequate evidence that the Life2000 system is beneficial in the treatment of COPD, or that it is superior to supplemental oxygen alone. It is not a true ventilator.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Life2000 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Life2000 system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an out of area specialist to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that the member has seen this provider in the past and needs to see her again. You also say that the member cannot receive this specific type of consultation in her home state and will need to travel to Colorado. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 at issue in this case is not a network provider with the Plan. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an office visit. Our reviewer says that the record does not document the medical necessity or reasonableness, as defined by Medicare rules, of the out of network visit. Our physician reviewer found the record indicates that the enrollee has posterior cortical atrophy. The plan has indicated that it has an in-network provider who is a neuro-ophthalmologist, and this reviewer has confirmed that fact. The record indicates that the in-network provider is available. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met.

The Plan has network providers available who can provide the items/services at issue in this appeal. The records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve an office visit. Therefore, we decided that the Plan does not have to pre-approve an office visit with an out of area specialist to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc injection left knee.
You asked the Plan to pre-approve Hyaluronan or derivative, monovisc, for intra-articular injection, per dose (J7327). You say that the enrollee has experienced pain for over 12 weeks. The Plan denied your request. The Plan says gel injections cannot be repeated within 6 months.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Hyaluronan or derivative, monovisc, for intra-articular injection, per dose (J7327). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee had a gel injection in the left knee on February 23, 2021 that decreased his knee pain by 50%. He had another injection on May 25, 2021. A repeat gel injection could be repeated in 6 months. However, the request to repeat this gel injection in August does not meet the coverage criteria. The review has determined that the requested repeat hyaluronan injection (Monovisc) is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyaluronan or derivative, monovisc, for intra-articular injection, per dose (J7327) have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc injection left knee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you want to go to rehab because you live alone and will need someone to help you get up. The Plan denied your request. The Plan says your needs could be met in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve an IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Iodine 1-123 ioflupane, diagnostic, per study dose, up to 5 millicuries (A9584) provided on January 8, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the items provided.
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 20% coinsurance for each Medicare-covered medical supply. Supplies for which an appropriate separate charge is made by providers (such as, chemical agents used in certain diagnostic procedures) are subject to cost-sharing.
You have been asked to pay $562.70 (Plan allowed amount of $2,813.52 x 20% insurance) for the Medicare-covered chemical agents provided for the diagnostic procedure. 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 coinsurance for the Iodine 1-123 ioflupane, diagnostic, per study dose, up to 5 millicuries (A9584) provided on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (86078) provided to the enrollee on November 24, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment for this service would be included in the part-A DRG payment to the facility.
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 86078 is "Blood bank physician services." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found while a patient is inpatient status, payments are made to the inpatient facility. Arrangements would be made between the inpatient facility and outside vendors.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (86078) provided to the enrollee on November 24, 2020
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 SNF care. You say that this care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee is a 68-year-old female with a
past medical history of hypertension who presented to the acute hospital on August 1, 2021 with a right hip
fracture after a fall. Based on the medical records provided, this patient does not require skilled nursing
services but does require skilled therapy services. However, these services are not required on a daily basis.
This patient does not require the services on an inpatient basis only in a skilled nursing facility setting. Services
in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this
case.
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 admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture (D5214), and an upper partial denture (D5213).
You asked the Plan to pre-approve a lower partial denture, and an upper partial denture. You say that you want the Plan to cover the services. The Plan denied your request. The Plan says the services are a covered benefit, but the enrollee has exceeded the frequency limit of one every 5 calendar 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. Based on this information, we decided that the Plan's rules for coverage of a lower partial denture, and an upper partial denture have not been met. Specifically, the record shows that the enrollee had exceeded the frequency limit prior to this service on February 28, 2018.
Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5214), and an upper partial denture (D5213).