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

We decided that the Plan does not have to pre-approve an 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 for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for chest pain and had coronary artery bypass grafting, aortic and mitral valve replacement and left atrial appendage repair. She had post-operative cardiac arrest requiring intubation and has been extubated. Her medical conditions are stable. 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. The patient 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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341).

You asked the Plan to pre-approve periodontal scaling and root planing. You say that the enrollee's general dentist recommended she have this service and referred the enrollee to a specialist due to dementia and special needs. The Plan denied your request. The Plan says the requested work is within the scope of the assigned general practitioner and should be completed by the assigned general practitioner.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers periodontal scaling and root planing when the services are medically necessary and reasonable.

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 periodontal scaling and root planing. Our reviewer says that in this case, the enrollee was referred to a periodontist by a general dentist. The Plan states the enrollee is assigned to a plan dental practice. The records do not indicate a medically reasonable and necessary rationale why the enrollee needs to be treated by a non-plan provider and why the plan provider would not be appropriate. The elements of the coverage rule are not satisfied. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an eye examination (92004) provided on February 17, 2021.

You asked the Plan to waive the co-payment for an eye examination. You say that you feel the provider billed the service incorrectly and you want the Plan to waive the co-payment. The Plan denied your request. The Plan says the co-payment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 co-payment for a medical eye examination.

You have been asked to pay a $35 co-payment for an eye examination. A medical eye examination falls within the Vision 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 co-payment for an eye examination (92004) provided on February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of a tunneled central venous catheter (36589)
and the fluoroscopic guidance for a central venous access device placement (77001) rendered by the OON
provider on January 15, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan 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 removal of a tunneled central venous catheter (36589) and the fluoroscopic
guidance for a central venous access device placement (77001) rendered by the OON provider on January 15,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that you have health issues, and the claim should be paid. The Plan denied your request. The Plan says this compression stocking is non-covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are non-covered 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 pre-approve compression stockings identified with code A6549.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 5, 2020 to December 7, 2020.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that the clinical criteria has not been met.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. 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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that, in this case, the 68-year-old enrollee was brought to the hospital after a low velocity motor vehicle crash without airbag deployment. The enrollee was evaluated for syncope and decreased responsiveness. The enrollee was transferred from the hospital to a trauma center. The medical record indicates that the treating physician had a reasonable expectation that the stay would span two midnights. The elements of the coverage rule are satisfied. The requested service is recommended.

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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from December 5, 2020 to December 7, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that this patient would be safely and equally well served with skilled
therapy services at an alternative 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 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. The
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness and hip
contusion after a fall. The enrollee's medical conditions are stable. 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. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria
for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the endosteal implant (D6010) and abutment supported porcelain fused to metal crown (D6059). We decided that the Plan does not have to pre-approve the prefabricated abutment (D6056).

You asked the Plan to pre-approve a surgical placement of implant body: endosteal implant (D6010), prefabricated abutment (D6056), and abutment supported porcelain fused to metal crown (D6059). You say that you need these services to be approved for coverage. The Plan says that the prefabricated abutment is not covered under your benefit plan. The Plan also says that the abutment supported porcelain fused to metal crown is only approved if there is record on an approved implant, or you already have an implant, and the records do not show either of these for you.

We decided that the Plan has to pre-approve the endosteal implant (D6010) and abutment supported porcelain fused to metal crown (D6059).

The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the IRE.

The Plan says that tooth implants are not a covered service. The EOC states that implants are a covered service, and the ORM lists endosteal implant (D6010) and abutment supported porcelain fused to metal crown (D6059) as covered benefits. The Plan did not provide valid denial reasons for these services. Therefore, we decided that the Plan has to pre-approve the endosteal implant (D6010) and abutment supported porcelain fused to metal crown (D6059).

We also decided that the Plan does not have to pre-approve the prefabricated abutment (D6056).

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 prefabricated abutment (D6056) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the prefabricated abutment (D6056).

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.
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 these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness and urinary retention. The enrollee's medical conditions are stable. 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. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee arthroscopy rendered on December 15, 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 procedure code 29879 is not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 29879 is 1. You billed 2 units of this code, exceeding the MUE. 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 knee arthroscopy rendered on December 15, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on September 2, 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 claim has not been processed by the primary insurer.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed that an Explanation of Benefits (EOB) has not been received by the primary insurer. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the biofeedback training (90901) provided
from July 9, 2020, through July 28, 2020.

You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services are not a covered benefit under
your contractual policy or by Medicare.

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 services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to issue reimbursement for the biofeedback training (90901) provided from July 9,
2020, through July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision of lesion of mucosa and submucosa (40812)
provided on November 17, 2020.

You asked the Plan to pay for the excision of lesion of mucosa and submucosa. You say that you feel that this
service should be covered. The Plan denied your request. The Plan says the treating provider opted out of
Medicare effective June 17, 2019, to June 17, 2021. The Plan also says that charges incurred by Medicare opt
out providers will not be reimbursed.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
excision of lesion of mucosa and submucosa (40812) provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vitamin injections with electric stimulation therapy provided
September 28, 2020.

You asked the Plan to pay for the vitamin injections with electric stimulation therapy. You say that the services
were medically necessary. The Plan denied your request. The Plan says these services are not considered
standard of care and the records provided do not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that the billed services are not supported in the medical record. Specifically, the documentation
provided was insufficient to support the billed CPT codes. The records provided do not support the physical
therapy codes billed. Based on this information, we decided that Medicare rules for coverage of the vitamin
injections with electric stimulation therapy have not been met. Therefore, we decided that the Plan does not
have to pay for vitamin injections with electric stimulation therapy provided September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1845).

You asked the Plan to pre-approve the knee orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says to meet coverage knee instability must be documented by examination of the member and objective description of joint laxity.

The Plan must follow Medicare rules. Medicare rules say that there must be documented objective joint laxity or instability. There also could be recent injury or surgery to meet coverage. No recent injury or surgical procedure is noted. No joint laxity or instability was documented. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1845).