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 you disagree with the denial. The Plan denied your request. The Plan says the requested IRF care is not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for a ruptured cerebral aneurysm. She is now medically stable with no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. She does require physical and
occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that the 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: 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 has complex medical needs that will benefit from further monitoring at the SNF. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. While the enrollee does have skilled therapy needs, these needs are not on a daily basis. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient mental health services provided on October 23, 2020.
You asked the Plan to waive the copay for the services provided. You say that the plan has been paying this claim for the past five years. The Plan denied your request. The Plan says the claim processed correctly.
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 $40 copay for each Medicare-covered individual therapy session for outpatient mental health care. You have been asked to pay a $40 copay for the services provided. the services provided falls within the outpatient mental health care 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 copay for the outpatient mental health services provided on October 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Caris MPI testing rendered on October 16, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when specific criteria are met. 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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of recurrent metastatic adenocarcinoma of the colon. The enrollee does have recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; however, the documentation does not support that comprehensive tumor profiling is reasonably expected to impact the management and outcome of the enrollee in this case. The testing was not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the Caris MPI testing rendered on October 16, 2020.
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 for the enrollee.
You asked the Plan to pre-approve IRF 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 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 the complexity of the 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 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. 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751), and core buildup (D2950).
You asked the Plan to pre-approve a crown, and core buildup. 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 crown (D2751), and core buildup (D2950).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 6 skilled nursing visits (G0299) and an additional 7 physical therapy visits (G0151).
You asked the Plan to pre-approve the home health services. You say that the requested services are medically necessary. The Plan denied your request. The Plan says the enrollee does not require further skilled services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the additional home health services are not medically necessary. Our physician reviewer found there is no evidence of complex wound care, new enteral feedings, IV antibiotics or other SN need. The reviewer found that the records do not show that skilled therapy services are required for the enrollee's functional level to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. Therefore, the reviewer found that the requested additional home health services are 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 the home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 6 skilled nursing visits (G0299) and an additional 7 physical therapy visits (G0151).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a metabolic positron emission tomography (PET) scan.
You asked the Plan to pre-approve the PET scan. You say that the PET scan was order to help differentiate if the enrollee's symptoms are related to her aneurysm, anxiety, and/or a neurodegenerative condition. The Plan denied your request. The Plan says the records show the enrollee has a problem that affects her recall memory. The Plan says that the records do not show that the enrollee's doctor needs the requested study in order to discern AD from FTD.
The Plan follows Medicare rules. Medicare rules say that a PET scan for the evaluation of dementia is covered in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both AD and FTD. 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 PET scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is not noted to meet diagnostic criteria for both AD and FTD. Rather, she is not currently indicated as meeting diagnostic criteria for either indication. As Medicare only covers this service to differentiate between AD and FTD, and the enrollee doesn't meet these indications (and has other differential causes for her symptoms) this service would not meet the requirements of the NCD for coverage. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a metabolic positron emission tomography (PET) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the patient requires LTACH level of care as she is a high risk for poor outcome, including death, if discharged to any other lower level of care. The Plan denied your request. The Plan says that records show the enrollee no longer has an illness that is complex enough to require further hospital care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee was admitted with a bowel obstruction and required several surgeries. The enrollee has had complications that require ongoing acute care services. The enrollee is receiving total parenteral nutrition and long-term antibiotics. The enrollee requires acute care services that have not been denied. The records provided do not indicate that the enrollee requires acute care services that she is not currently receiving that would otherwise be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet
Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI), of the spinal canal and contents, thoracic; without contrast material (74126) provided on December 3, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $100 copay per visit for all other outpatient diagnostic and therapeutic services and supplies, such as MRA's, MRI's, CT scans, PET scans, and hyperbaric oxygen therapy.
You have been asked to pay a $100 copayment for the outpatient diagnostic service provided. 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 the magnetic resonance imaging (MRI), of the spinal canal and contents, thoracic; without contrast material (74126) provided on December 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that this is medically necessary. The Plan denied your request. The Plan says that a total electric hospital bed is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81405, 81406, 81408, and 81479 provided on September 25, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 the laboratory services coded 81405, 81406, 81408, and 81479 are not supported in the medical record. Specifically, when a laboratory assays two or more genes in a patient in parallel those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel.
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81405, 81406, 81408, and 81479 provided on September 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent injections.
You asked the Plan to pre-approve Praluent. You say that the enrollee is well controlled, and he tolerates the
medication well. The Plan denied your request. The Plan says Praluent to be administered at home is not
covered under the Part B 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 Praluent injections.
Benefits for Praluent 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the segmented gradient pneumatic appliance (E0673) provided on November 17, 2020.
You asked the Plan to pay for the segmented gradient pneumatic appliance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this device is the responsibility of the facility.
The Plan must follow Medicare rules. Medicare rules say that if the base PCD is not covered, related accessories are not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the segmented gradient pneumatic appliance have not been met. Specifically, the record does not indicate that the base PCD was covered so the billed accessory is not eligible for reimbursement. Therefore, we decided that the Plan does not have to pay for the segmented gradient pneumatic appliance (E0673) provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 16, 2021, and February 23, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 16, 2021, and February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested device. You say that the enrollee is not currently using insulin. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to pay for inpatient care billed to the enrollee for October 17, 2021.
You asked the Plan to pay this claim. You say that this claim should be paid by the Plan. The Plan denied your
request. The Plan says the claim date billed as inpatient care is not supported by the medical records. We
overturned the Plans denial for insufficient information submitted to support their decision. The Plan requested
a reopen and provided additional records. The Plan says that medical record provided show the date and time
that the enrollee was admitted as an inpatient which was on October 18, 2020 at 12:47AM. The Plan states this
claim was incorrectly billed with an inpatient place of service code for October 17, 2020. There is no
documentation to show the enrollee was admitted as an inpatient to the facility on the date billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes and documentation.
In this case, the date submitted on the claim is not substantiated by the medical records. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care billed to the enrollee for October 17, 2021.