Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you are needing wound care to prevent infection. The Plan denied your request. The Plan says the stay is not medically necessary.
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 there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that is not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and are able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from December 30, 2020, to January 6, 2021.

You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you had met your maximum out-of-pocket amount. You are questioning why the $303.57 was not paid. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount. The Plan says your contract with them ended on December 31, 2020.

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 $289 copayment per day, days 1 to 7 at an in-network inpatient hospital.

You have been asked to pay a $303.57 copayment for the inpatient hospital admission. This is less than the standard copayment amount because you met your $6,700 maximum out-of-pocket amount with this claim. The inpatient hospital admission falls within the "Inpatient hospital 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 copayment for the inpatient hospital admission provided from December 30, 2020, to January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital services (99232) provided March 4, 2021.

You asked the Plan to pay for the subsequent hospital services. You say that you would like reconsideration because the payment for these services is not included in the payment for the services of another physician. The Plan denied your request. The Plan says the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital services have not been met. Specifically, CPT code 99232 was billed on the same date of service as another evaluation and management service rendered by a provider in the same group with the same specialty. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital services (99232) provided March 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that you have two surgeries and require help with your recovery. The Plan denied your request. The Plan says the enrollee's condition does not meet the guidelines for coverage of SNF care. The Plan says that the enrollee's needs can be met at a lower level of care.

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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON physical therapy services. You say that the enrollee received referral for pelvic floor therapy over a month ago. The Plan denied your request. The Plan says there is not a network deficiency. The Plan says that the requested OON provider has not seen the enrollee before, and the enrollee is not in a current treatment plan. The Plan says that the requested OON provider does not supply any specialty that the network providers cannot supply.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the partial dentures (CPT code D5225).
You asked the Plan to pre-approve the partial dentures. You say that you cannot wear the metal as they irritate your mouth and it causes sores. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your Preventive & Comprehensive Dental Coverage Customer Handbook as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve the partial dentures (CPT code D5225).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from July 25, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that you are needing to leave from the hospital to a group home for psychiatric help. The Plan denied your request. The Plan says the continuation of mental health care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our
physician reviewer found based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of July 25, 2021, forward and could have been treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any abnormal behaviors being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care from July 25, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neurology services (CPT 95957) provided to the enrollee on August 17, 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 Current Procedural Terminology (CPT) code 95957 (1 unit) remains not supported.
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 95957 is "Digital analysis of electroencephalogram (EEG) (e.g., for epileptic spike analysis)." 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 the medical records does not include documentation of spikes in the physician's report, therefore, it is inappropriate to use CPT 95957 when no spikes are present.
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 neurology services (CPT 95957) provided to the enrollee on August 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio for the enrollee.
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the member has not tried and failed Stelara.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 Entyvio. Our reviewer says that Entyvio is not medically reasonable and necessary for the enrollee. The Plan requires a trial of Remicade OR Inflectra; AND Stelara before they will approve Entyvio. The patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Entyvio. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs medical assistance from an IRF as soon as possible. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 Our physician reviewer found 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. The enrollee was admitted for surgical repair of hip fracture and wrist fracture after a fall. The enrollee's 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.reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for common procedural terminology (CPT) code 99233 billed for dates of service October 19 - October 23, 2020.
You asked the Plan to pay for CPT code 99233. You say that the services rendered were medically necessary and the medical records support the services billed. The Plan denied your request. The Plan says the CPT code in dispute is not supported by the records provided.
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 99233 is Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. We asked our coding specialist 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 CPT code 99233. Our coding specialist reviewer says that the criteria for coverage of CPT code which remains in dispute, have not been met. Our coding specialist reviewer found the documentation supports a comprehensive history and comprehensive exam. However, the documentation does not support medical decision making of high complexity. For this visit, respiratory and gastric diagnosis were addressed, which falls under multiple diagnoses addressed. The documentation addresses moderate level of data reviewed with labs, intake and output, radiology, and KUB. The documentation supports moderate level of risk of significant complications, morbidity, and/or mortality, with tests equaling less than 12 points. Therefore, a more appropriate code to report for this service is CPT 99232. We looked at this coding specialist's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 99233 have not been met. Therefore, we decided that the Plan does not have to pay for common procedural terminology (CPT) code 99233 billed for dates of service October 19 - October 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428, A0425) provided on December 8, 2020.

You asked the Plan to pay for the non-emergency ambulance transportation. You say that the Plan should cover the non-emergency ambulance transportation. The Plan denied your request. The Plan says non-emergency ambulance transportation is covered when it is the only way to safely and adequately transport an enrollee, or if other means of transporting an enrollee are unsafe due to a medical condition.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the non-emergency ambulance transportation. Our reviewer says that the enrollee was transferred via ambulance from home to the dialysis center. The documentation does not support that a stretcher van was contraindicated, which would have safely transported him to his dialysis center, nor does it support that he required any form of special equipment or expertise during transport.

Our physician reviewer found the documentation does not support that the non-emergency ambulance transport on December 8, 2020 was medically reasonable or necessary for the enrollee.

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 non-emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428, A0425) provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation services.

You asked the Plan to pre-approve lumbar facet joint radiofrequency ablation services. You say that this request is medically necessary and reasonable. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic facet joint procedures require two diagnostic facet joint procedures. 

We looked at the file and Medicare rules. In this case, the enrollee has not completed two diagnostic facet joint procedures. Based on this information, we decided that Medicare rules for coverage of lumbar facet joint radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated at a lower 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. Our physician reviewer found the patient does not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the patient does require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.