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

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the physician is recommending acute inpatient rehabilitation to improve functional outcomes of impaired mobility. The Plan denied your request. The Plan says the stay 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 considered medically reasonable and necessary based on Medicare guidelines. 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 lumbar laminectomy and fusion. 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair management (97542), oral function therapy (92526), and evaluation of occupational therapy (97165) provided on October 15, 2020, to November 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the wheelchair management, oral function therapy, and evaluation of occupational therapy. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for services rendered by an OON provider.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the wheelchair management (97542), oral function therapy (92526), and evaluation of occupational therapy (97165) provided on October 15, 2020, to November 16, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you need the shoes because you are in pain. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Medicare rules also say that the quantity of diabetic shoes and inserts is limited.

Records show that you suffer from diabetic foot disease. The records also show that the Plan authorized coverage for a pair of diabetic shoes and 3 pairs of inserts on February 2, 2021. Although orthotics are appropriate for you, neither Medicare nor the Plan provides coverage for more than 1 pair of diabetic shoes and more than 3 pairs of inserts, per calendar year. This means that your benefit for these items is currently exhausted. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (PWC).

You asked the Plan to pre-approve a PWC. You say that this is medically necessary for you.The Plan denied your request. The Plan says that there is no documentation member is unable to use of an appropriately fitted cane or walker for mobility.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 a PWC. Our reviewer says that a PWC is not medically reasonable and necessary in this case. There is documentation that you have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. There is no documentation that your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair. A note dated May 10, 2021, indicates you were using a single point cane to get around at that time. There is no documentation that the patient can safely operate a power mobility device. Our physician reviewer found that your condition does not meet Medicare criteria for a PWC.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PWC have not been met.Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (PWC).
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 would like rehab to be covered for you. The Plan denied your request. The Plan says that your needs can be met 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for chest pain. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy, initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (97803) provided October 2, 2020.

You asked the Plan to pay for medical nutrition therapy. You say that please review claims for possible reimbursement according to provider contracted rates. These are medically necessary services and you have attached medical records. The Plan denied your request. The Plan says non-emergent services with non-contracted providers require prior authorization before services being rendered.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. The plan offers a medical nutrition therapy benefit that exceeds Medicare. For that reason, the Plan's rules apply in this case.

The plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can receive your care from either a network provider or an out-of-network provider. The health Plan contract specifically says prior authorization is required. The Plan did not pre-approve the item/service 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 medical nutrition therapy, initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (97803) provided October 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and
services.
You asked the Plan to pay for IRF care. You say that that these services are medically necessary; you are
completely dependent on others and not able to walk on your own. You have several medical issues and would
benefit greatly from IRF services. The Plan denied your request. The Plan says based on your current medical
stability, lack of medical complexity and current level of function, there is no need for physician supervision 3
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic
medical conditions, and you do not require an intensive, complex, multidisciplinary approach to daily therapy.
Criteria for admission to the IRF have not been met. Your ongoing skilled therapy and nursing needs can be
provided 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 pay for 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 your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require
physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different
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 pay for 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 the established patient assisted living visit (99335) provided on November 30, 2020, by an out of network (OON) provider.

You asked the Plan to pay for the established patient assisted living visit. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the established patient assisted living visit (99335) provided on November 30, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150) provided on April 1, 2021, by an out-of-network provider.
You asked the Plan to pay an additional amount for the evaluation. You say that you were told these services would be covered and that you were given misinformation. The Plan denied your request. The Plan says they do not generally cover out-of-network services, but in this case the requested evaluation was approved and covered. The claim was correctly paid up to the maximum allowable fee for an out-of-network provider. You may be billed for any amount between what was billed by the provider and what was paid by the Plan.
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. 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 requested provider in this case is not a network provider with the Plan. Documentation shows that the Plan paid the maximum allowable fee for this service. In-network providers have agreed to be paid this fee, but out-of-network providers do not participate in this agreement. Because this provider is not in-network and dental care is covered by your supplemental benefits, the provider is allowed to ask you to pay the remainder of the bill. Therefore, we decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150) provided on April 1, 2021, by an out-of-network provider.
Your complaint about potential misinformation is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion (11056) and trimming of nondystrophic nails (11719) provided on March 10, 2021.

You asked the Plan to pay for the paring or cutting of a benign lesion and trimming of nails. You say that you would like reconsideration because these codes do not require a modifier when reported together. The Plan denied your request. The Plan says these codes were billed without the required modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT codes 11056 and 11719 are not supported in the record. Specifically, per the LCA, these codes must be reported with modifier Q7, Q8 or Q9. This claim was billed without the required modifiers. Based on this information, we decided that Medicare rules for coverage of the paring or cutting of a benign lesion and trimming of nails have not been met. Therefore, we decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion (11056) and trimming of nondystrophic nails (11719) provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on
December 29, 2020.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 a domiciliary, rest home visit provided on December 29, 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.

You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on February 19, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided on February 19, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on March 4, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the claim was submitted with all Medicare-approved codes and they should be covered. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on March 4, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete set of dentures (D5110, D5120).

You asked the Plan to pre-approve a set of dentures. You say that the set of dentures you previously received does not work. The Plan denied your request. The Plan says rules for a set of dentures have not been met.

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 benefit includes complete or partial dentures up to 1 set every 5 calendar years. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a set of dentures have not been met. Specifically, the Plan has attested that you received a prior set of dentures on January 19, 2021. The denture benefit is now exhausted for 5 calendar years as explained in the Plan contract. Therefore, we decided that the Plan does not have to pre-approve a complete set of dentures (D5110, D5120).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Esophagogastroduodenoscopy provided on March 22, 2021.
You asked the Plan to waive the copayment for the Esophagogastroduodenoscopy. You say that the procedure didn't do what was needed so you will have other copays for tests and procedures. The Plan denied your request. The Plan says the copayment was applied appropriately to your outpatient surgical benefit.
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 $245 copayment for Outpatient Surgery. You have been asked to pay a $245 copayment for the Esophagogastroduodenoscopy. The Esophagogastroduodenoscopy falls within the Outpatient Surgery 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 Esophagogastroduodenoscopy provided on March 22, 2021.