Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rate for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the filling (D2335) provided from January 23, 2020, to January 24, 2020.
You asked the Plan to pay the in-network rate for the dental services. You say that this provider is in network according to your book. You say that you paid $453.80 for the services. You say that the provider called you later and advised you had a credit of $270.40. You also say that the filling kept falling out so you had to go back 4 times. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that while you can get care out of network, you may pay more for these 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, you can get care out of network, but you may pay more for those services. Out of network providers may bill you for any amount greater than what the Plan pays.
Date of Service
CPT Code
Billed
Allowed
Difference
Plan Paid
Deductible
Your Responsibility
1/23/2020
D0140
$98
$45.60
$52.40
$45.60
$0
$52.40
D0220
$39
$23
$16
$23
$0
$16
1/24/2020
D2335
$395
$12
$383
$9.60
$100
$385.40
TOTAL:
$453.80
Therefore, we decided that the Plan does not have to pay the in-network rate for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the filling (D2335) provided from January 23, 2020, to January 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.
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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 for the enrollee.
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 the clinical documentation provided supports the need for SNF care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage, as there are not skilled needs identified.

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 patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this patient does 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 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: 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 the records provided support the need for SNF care. The Plan denied your request. The Plan says daily skilled services are not required and that the criteria for coverage of 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.

You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a skilled nursing facility admission.

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 SNF admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits and treatment to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve office visits and treatment to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 office visits and treatment to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued inpatient hospital care provided from 4:07PM on November 9, 2020, through November 10, 2020.

You asked the Plan to pay for the continued inpatient hospital care. You say that the inpatient admission was medically necessary and should be covered. The Plan denied your request. The Plan says the enrollee was stable for transfer, and no authorization was requested for post-stabilization care.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 continued inpatient hospital care. Our reviewer says that the enrollee appears to have been stable for transfer to a network facility as of the date/time in question. Our physician reviewer found the patient is a 65-year-old female who presented to the emergency room with shortness of breath and hypoxia (78% on room air). She was treated with oxygen. Later on 11/9/2020, she was able to be reduced from 10 liter per minute to 5. Her breathing was stable and without distress. Up until around 4 pm on that day, she had been in more distress requiring more oxygen support but had improved enough to be hemodynamically stable and with pulmonary stability sufficient for transfer.

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 continued inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the continued inpatient hospital care provided from 4:07PM on November 9, 2020, through November 10, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for outpatient laboratory testing (80053, 36415, 83690, 85027) provided on
December 5, 2020,
You asked the Plan to pay for outpatient laboratory testing. You say that the services were medically necessary.
The Plan denied your request. The Plan says that services were provided by an out-of-network provider without
prior authorization.
The Plan must follow Medicare rules. Medicare rules say that an emergency medical condition is a medical
condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a
prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in negative outcomes. Emergency medical condition status is not affected
if a later medical review found no actual emergency present.
We looked at the file and Medicare rules. The enrollee presented to the emergency department with nausea and
vomiting for the past two days and had decreased intake because of this. The outpatient laboratory testing was
done to evaluate the enrollee's emergency condition. Under Medicare rules, this means the outpatient
laboratory testing is considered approved by the Plan. Therefore, we decided that the Plan has to pay for
outpatient laboratory testing (80053, 36415, 83690, 85027) provided on December 5, 2020,
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve air ambulance transportation.
You asked the Plan to pre-approve air ambulance transportation. You say that air ambulance transport is necessary for the enrollee to be closer to family. The Plan denied your request. The Plan says this transportation is not a covered benefit when not being requested for medical reasons.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.
We looked at the file, and Medicare rules. In this case, there is no medical need for air ambulance transportation. All the enrollee's medical needs are currently being satisfied in the current acute care hospital. The request for air ambulance transportation would not be for medical necessity but would help the enrollee be closer to family. Under Medicare rules, air ambulance transportation is not covered for this reason. Based on this information, we decided that Medicare rules for coverage of air ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve air ambulance transportation
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the office or other outpatient visit for the evaluation and management of a new patient (99203), frames (V2020), spherocylinder, bifocal lenses (V2203), lens, polycarbonate (V2784), anti-reflective coating, per lens (V2750), ultraviolet (UV) lens, per lens (V2755), and prism, per lens (V2715) provided February 4, 2021.

You asked the Plan to provide additional payment for the office visit, frames and bifocal, polycarbonate, UV, prism lenses with anti-reflective coating. You say that your services should be covered. The Plan denied your request. The Plan says the medical eye was covered correctly with a $20 copayment. The routine eyewear has been covered up to the maximum $100 allowance.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says you have a $20 copayment for medical eye exams. The Plan covers routine eyewear up to a maximum $100 allowance.

We looked at the file and the Plan's rules. You have been asked to pay a $20 copayment for your medical eye exam. Additionally, the documentation shows that the Plan has covered your routine eyewear up to the maximum $100 vision hardware allowance. Based on this information, we decided that the costsharing for the vision services has been applied correctly. Therefore, we decided that the Plan does not have to provide additional payment for the office or other outpatient visit for the evaluation and management of a new patient (99203), frames (V2020), spherocylinder, bifocal lenses (V2203), lens, polycarbonate (V2784), anti-reflective coating, per lens (V2750), ultraviolet (UV) lens, per lens (V2755), and prism, per lens (V2715) provided February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thermal facet joint radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation provided shows the first block only provided 50% pain relief.
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 the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the LCD requires 80% pain relief from two sets of diagnostic medial branch blocks. This was not achieved.
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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal facet joint radiofrequency ablation for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacral nerve radiofrequency ablation.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational because of the wide variation in efficacy reported in the literature. Therefore, the request is considered not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacral nerve radiofrequency ablation
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a folding wheeled walker with seat attachment for the enrollee.
You asked the Plan to pre-approve the walker. You say that this is medically necessary. 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 pre-approve the walker. Our reviewer says that the requested walker is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the enrollee in this case has a mobility limitation that significantly impairs her ability to participate in one or more mobility-related activities of daily living in the home. 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 walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a folding wheeled walker with seat attachment for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Tecentriq (J9022).

You asked the Plan to pre-approve Tecentriq. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Tecentriq. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that the Medicare-approved compendia indicate the results of PD-L1 testing are pertinent to determining the medical necessity of treatment with Tecentriq in combination with Abraxane. PD-L1 results were not provided in the case record.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Tecentriq (J9022).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 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 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 pneumonia, weakness and falls. 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 patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this 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 for the enrollee.