Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 22, 2018 to February 28, 2018.

You asked the Plan to pay for home health services. You say that these services were billed correctly. The Plan denied your request. The Plan says the HHRG code on the claims indicates there were Non-Routine Supplies (NRS) provided, but are not submitted on the claim.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claims for these services were billed with a HIPPS code with an S in the fifth position. This indicates that supplies were provided during this home health episode. However, no supplies were billed on these claims, meaning the HIPPS code is incorrect in this case. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 22, 2018 to February 28, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an all lower extremity prosthesis, shank foot system with vertical loading pylon with Prevail Prosthetics Orthotics.You asked the Plan to pre-approve a shank foot system with vertical loading pylon (A5987). You say that the requested foot will allow the enrollee to continue full functioning.The Plan denied your request. The Plan says medical criteria for a K3 foot was not corroborated.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 shank foot system with vertical loading pylon (A5987). Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found this is a convenience item-there is no indication a standard foot (SACH foot or carbon-fiber) could not safely and adequately address the enrollee's needs.  As such, this requested foot  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 a shank foot system with vertical loading pylon (A5987) have not been met.Therefore, we decided that the Plan does not have to pre-approve an all lower extremity prosthesis, shank foot system with vertical loading pylon with Prevail Prosthetics Orthotics.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance servicesprovided on August 5, 2019 by an out of network provider.You asked the Plan to pay forthe non-emergent ambulance services. You say that the services were medically necessary.The Plan denied your request. The Plan says you did not request 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the servicesat 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 forthe ambulance services provided on August 5, 2019 by an out of network provider.We are dismissing your case for services provided on August 12, 2019. This appeal must be reprocessed by the Plan. Medicare rules say that a non-contract provider can make an appeal request only when it has agreed to waive its right to payment from the enrollee. The rules further say that if a non-contract provider files a request for reconsideration of a denied claim without a waiver of liability form, the Plan must make and document reasonable efforts to obtain the waiver of liability form. You can find this rule in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Grievance Manual, Section 
50.9.  In this case, the record does not show that the Plan made any attempts to obtain a waiver of liability documentfor date of service August 12, 2019. Therefore, we are dismissing the case and referring this issue back to the Plan. The Plan should provide the appellant with a waiver of liability form and instructions for completion. Once a valid waiver is received, the plan should complete the plan level review. If the Plan decides it will not pay for the services provided, the Plan will send the case back to us as a new appeal. A new case number will be assigned.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.The Plan must follow Medicare rules. The rules say thatMedicare pays for care in a SNF when the four factors listed above 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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member was admitted for acute care on 02/24/2020 and underwent an elective right total knee arthroplasty. Her hospital course was complicated by hyponatremia, a small bowel obstruction, and pulmonary edema. Her relevant past medical history includes hypertension, hyperlipidemia, chronic kidney disease, peripheral vascular disease, and coronary artery disease. The member lives alone in an apartment with ramp access and had been independent. She is weight-bearing as tolerated. Functionally, as of 03/03/2020 she required supervision for transfers and was ambulating 220 feet with standby assistance without loss of balance.The member is status-post elective right knee arthroplasty as described above without ongoing postoperative complication. The member continues to receive wound care. The member requires oversight of her medical conditions and medication management. The member has not returned to her prior level of function. The member requires physical therapy for progression of her mobility at a community level and to establish a 
maintenance home exercise program. An occupational therapy evaluation is indicated to assess the need for any adaptive equipment. There are skilled needs, but they do not need to be provided on a daily basis. The member is ambulating greater than household distances and performing essential activities of daily living without hands on assistance. The member's condition would not be expected to deteriorate with services provided on a less than daily 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 admission to a skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs prolonged care at the acute level which is the type of care thatan LTACH specializes in.The Plan denied your request. The Plan says an LTACH does not specialize in any care that cannot be provided in all other hospitals.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 the enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe porcelain crown (D2740) provided on July 9, 2019.You asked the Plan to pay forthe dental service. You say that the service was emergent. You say that you needed a new crown because the old one broke and your tooth's root nerve was exposed. You also say that you were in pain.The Plan denied your request. The Plan says crowns are not listed as a covered service.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 crown is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe porcelain crown (D2740) provided on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM) (K0554) and supplies (K0553).
You asked the Plan to pre-approve a FreeStyle Libre CGM and supplies. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not insulin treated, so the Medicare coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that a CGM is covered if the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump.
We looked at the file and Medicare rules. The submitted medical records show that the enrollee is not currently insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. Based on this information, the Medicare criteria for coverage of a FreeStyle Libre CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM) (K0554) and supplies (K0553).
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 requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.ThePlan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules todetermine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the enrollee admitted to acute care on 2/24/20 for chronic obstruction pulmonary disease (COPD) exacerbation, acute bronchitis, coronary artery disease (CAD), and acute on chronic respiratory failure. The enrollee's current level of function in therapy is ambulating 120 feet with stand by assistance and a rolling walker, independent with feeding, grooming with minimal assistance, bed mobility and upper body dressing with modified independence, lower body dressing with supervision, and toileting with minimal assistance. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says LTACH admission 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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for diarrhea and electrolyte abnormalities. The enrollee was apparently intubated/ventilated, but has since been extubated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from February 10, 2019 to March 11, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided to the enrollee on August 19, 2019.
You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says this is not
medically necessary.
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 pay for the anesthesia services. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that sedation is not considered appropriate for epidural steroid injection, as delineated by the
ASA Committee on pain statement on sedation during interventional pain procedures.
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 anesthesia services have not been met. Therefore, we decided that the Plan
does not have to pay for the anesthesia services provided to the enrollee on August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on November 6, 2019.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you called the Plan and were told that this provider was in-network. You also say that the provider's office informed you that they were in-network as well. The Plan denied your request. The Plan says these services were rendered by an out-of-network provider.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on November 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission. You asked the Plan to pre-approveIRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary.The Plan denied your request.The Plan says that you do not meet criteria for coverage of an inpatient rehabilitation facilityadmission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as describedabove.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 rehabilitation facilitycare. Our reviewer says that the requested inpatient rehabilitation facilitycare is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical,and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an acute inpatient rehabilitation stay with close physician or nursing supervision.You may benefit from andparticipate in additional physical andoccupational therapy, but you do not require this on an intensive rehabilitation therapy program level in an inpatient rehabilitation facility.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-approvean acute inpatient rehabilitation facility (IRF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe cleaning provided on October 28, 2019.You asked the Plan to reimburse you forthe dental service. You say that when you contacted member services, you were not informed that it was mandatory to use a plan dental provider. You also say that the Plan did not provide any plan documentation or a provider's book until the end of March 2019.The Plan denied your request. The Plan says the provider in this case is nota network provider. The Plan also says that preventive and comprehensive dental care is covered when provided by a participating dental provider. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceedsMedicare 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, dental services are not covered when received out of network. The record shows that the plan sent you a letter on July 24, 2019 that informed you that a one-time exception was made to cover the dental services from the out of network provider. The letter also said that any further visits to an out of network dentist will not be covered.Therefore, we decided that the Plan does not have to reimburse you forthe cleaning provided on October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the porcelain crown provided on October 16, 2019.You asked the Plan to waive the copayment for the porcelain crown. You say that you were not informed of the charges prior to receiving the services.The Plan denied your request. The Plan says your copayment has been applied according to your benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the contract clearly states that you must pay a $125 copayment for porcelain/stainless steel crowns.Therefore, we decided that the Plan does not have to waive the copayment for the porcelain crown provided on October 16, 2019.