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

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee does require skilled therapy services, i.e., the specialized skill, knowledge, and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. However, daily skilled services are not required. Based on the medical records provided, the enrollee does not require these services 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the retainer crown - porcelain fused to noble metal (D6752 x2), and the pontic - porcelain fused to noble metal (D6242 x2) received January 5, 2021 from the out-of-network provider.
You asked the Plan to pay an additional amount for the dental services. You say that after your $100 deductible you should only be responsible for 50% of the cost for the requested services. The Plan denied your request. The Plan says out-of-network providers can bill you for the difference between the Plan's allowed amount and the fully billed amount for the requested services.
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 only covered under this benefit up to the Plan's allowed amount when received from an out-of-network provider. An out-of-network can directly bill you for the difference between the Plan's allowed amount for a service the out-of-network provider's full billed amount. You have been asked to pay a $100 deductible. In addition, you have been asked to pay 50% coinsurance up to the Plan's allowed amount for the requested services. Any amount over the Plan's allowed amount for a particular service is your responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for the retainer crown - porcelain fused to noble metal (D6752 x2), and the pontic - porcelain fused to noble metal (D6242 x2) received January 5, 2021 from the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that this request is medically necessary for your
condition. The Plan denied your request. The Plan says being used in the bilevel positive airway pressure
(BiPAP) mode rather than being used as a home ventilator.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says
that the requested home ventilator is not medically reasonable and necessary. Our physician reviewer found in
this case, you have obesity and hypertension. In addition, you were hospitalized in April 2021 with COVID
pneumonia and acute hypoxemic respiratory failure. You were treated with oxygen and BiPAP. Medicare does
not cover a home ventilator when used as BiPAP. Certain BiPAP devices can provide the Average volumeassured
pressure support mode of ventilation that has been ordered. The denial is upheld.

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for outpatient wound care provided from January 7 through January 28, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was applied based on the services provided and the Plan contract agreement.
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 cost share for services rendered. 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 cost share charged for outpatient wound care provided from January 7 through January 28, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the enrollee requires an admission to a SNF. The Plan denied your request. The Plan says the treatment the enrollee needs can be provided in a lower level of care. The Plan also says that the enrollee does not require skilled nursing care as defined by Medicare rules.
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 admission. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that requires 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 SNF setting. We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) device.
You asked the Plan to pre-approve a TENS device (E0730). You say that the enrollee is responding well to the device and wishes to avoid surgery. The Plan denied your request. The Plan says the enrollee is not enrolled in an approved clinical study.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a TENS device (E0730).
We looked at the file and Medicare rules. The record shows the enrollee is not in a clinical study. Based on this
information, we decided that Medicare rules for coverage of a TENS device (E0730) have not been met.
Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation
(TENS) device
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for paravertebral injections (64492) provided on September 1, 2020, by an out of network (OON) provider.
You asked the Plan to pay for injections. You say that you obtained prior authorization for these services. The Plan denied your request. The Plan says prior authorization must be obtained for services rendered by an out-of-network 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 record does not contain
evidence of an approved authorization for the service at issue. 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 paravertebral injections (64492) provided on September 1, 2020, by an out of
network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that your wounds were not taken care of. The Plan denied your request. The Plan says the request is premature due to upcoming ankle surgery.

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 services. Our physician reviewer found that you do not require services of a skilled professional nurse to provide medically necessary treatment in a SNF. Your functional level has weight bearing limitations. At the time of request, you did not require therapy services of a qualified therapist to provide medically necessary treatment. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter at this time you do not require the necessary services on an inpatient basis, in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services you received on January 17,
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 prior authorization before receiving care.

The requested provider in this case is not a network provider with the Plan. The requested outpatient services
require prior authorization. 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 outpatient hospital services you received on January 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion of intravenous immune globulin (IVIG).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 

We looked at the file and Medicare and the Plan's rules. The file shows that the services at issue are home infusion of IVIG. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. The Plan has approved the services under the enrollee's Medicare Part D benefit. Therefore, we decided that the Plan does not have to pre-approve home infusion of intravenous immune globulin (IVIG).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee during a facility stay on December 16, 2020.
You asked the Plan to pay for the enrollees use of this equipment. You say that this claim should be paid. The Plan denied your request. The Plan says this claim should be submitted to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee during a facility stay on December 16, 2020.
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. The Plan denied your request. The Plan says the records do not support the need for an intensive rehab therapy program.

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 physician reviewer found that the enrollee was admitted to the acute care hospital for sepsis, urinary tract infection, and cardiac arrhythmia for which a permanent pacemaker was placed. Her medical conditions are stable. There are no complex nursing needs. 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.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided at the innetwork
benefit level by an out-of-network (OON) provider.
You asked the Plan to pre-approve physical therapy. You say that you may need surgery, but want to try
physical therapy to see if it would work before you go through with surgery. The Plan denied your request. The
Plan says the denial of authorization for coverage at the in-network benefit level is correct, because this
provider is out-of-network with the Plan and you can be treated by an in-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. Your contract with the
Plan says that you may choose to receive care from out-of-network providers. You pay $40 copayment for each
in-network covered physical therapy service or 40% coinsurance - after a $500 deductible is met - for each
out-of-network covered physical therapy service.
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 at the in-network benefit level. You may choose to use this
provider at the out-of-network benefit level. Therefore, we decided that the Plan does not have to pre-approve
physical therapy services to be provided at the in-network benefit level 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 the enrollee has pain with standing, walking and
activities of daily living as well as work. 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.
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot
orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) and core build up (D2950) for tooth # 7.
You asked the Plan to pre-approve the dental services. You say that your dentist advised that you need a root canal. You say that tooth # 7 has a deep cavity close to the nerve. You also say that this is medically necessary. The Plan denied your request. The Plan says there is a $250 allowance per quarter for covered dental services. The Plan also says that the allowance has been reached.
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 the dental services when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the allowance has been reached. The record shows that you had an available allowance of $500 at the time of the request.
The record also shows that the Plan approved $500 towards the root canal for tooth # 7, thus exhausting the available allowance. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) and core build up (D2950) for tooth # 7
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of physical therapy.
You asked the Plan to pre-approve a continuation of physical therapy. You say that the documentation provided supports that the enrollee would benefit from further skilled physical therapy intervention. You say that the enrollee is not a candidate for pain management or surgery at this time. The Plan denied your request. The Plan says the test scores do not show that the enrollee has made progress in her function with skilled treatment. The Plan says that skilled treatment is not needed to maintain the enrollee's function. The Plan says that the enrollee can continue with the home program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 continuation of physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The patient has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 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 continuation of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of physical therapy
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for equipment coded as L1833 and L2397 billed to the enrollee
for date of service March 16, 2021.

You asked the Plan to pay for this claim. You say that this equipment should be covered by the Plan. The Plan
denied your request. The Plan says there is insufficient documentation of appropriate orders and proof of
delivery

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain a valid physician order and the proof of delivery is not signed. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for equipment coded as L1833 and L2397 billed to the enrollee for date of service March 16, 2021.