Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe physical therapy services provided from January 7, 2019 to February 2, 2019.You asked the Planto pay forthe physical therapy services. You say that these services weremedically necessary and should be paid as the enrollee has out of network coverage.The Plandenied your request. The Plansaysthe claims provide conflicting information with more than one POS code being reported for the same date of service as well as discrepancies in the claim field reporting where the services took place.The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient information to determine whether payment is due.In this case, both home andoffice POS codes are reported often for the same date of service. Some claims report the services were provided at the patient's home address, others state they were provided at an assisted living facility. No records or documentation was submitted to clarify the location that the services were rendered or to show that these were not home health services, which would require billing via the Home Health Prospective Payment System. There is not sufficient documentation to support that the services that are being reported can be paid by Medicare.Therefore, we decided that the Plandoes not haveto pay forthe physical therapy services provided from January 7, 2019 to February 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consult and dental extractions to be provided by an oral surgeon.You asked the Plan to pre-approvethe dental services. You say that this is medically necessary.The Plan denied your request. The Plan says dental services provided by specialists, such as oral surgeons, periodontists, prosthodontics, and endodontists are not covered.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 serviceswhen the services are provided by a participating general dentist.The requested services are to be provided by an oral surgeon. This type of provider is not covered. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approvea consult and dental extractions to be provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services for the enrollee.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee has stabilized as much as possible in an inpatient setting. The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services from March 16, 2020 forward, were requested for 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 continued services. Our physician reviewer found that it did not appear that active treatment was taking place. The services were not reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. There is no individualized treatment plan. However, it did appear that the records were supervised and evaluated by a physician. Based upon review the records, the enrollee does not meet the criteria for continued acute inpatient mental health treatment for March 16, 2020 forward, as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvead mission to an inpatient rehabilitation facility (IRF). You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says care could be received in another setting.The Plan 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 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 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 PT and OT 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-approve admission to an inpatient rehabilitation facility (IRF)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee was rapidly discharged from the hospital due to the current medical environment and risk to his health. You say that the enrollee currently meets acute inpatient rehabilitation admission criteria under CMS guidelines. You say that the enrollee requires aggressive therapy and close physician monitoring. The Plan denied your request. The Plan says the requirement for medical necessity has not been established based on the information provided. The Plan say that the enrollee does not need a hospital level of rehabilitation or constant supervision by a doctor or nurse specialized in rehabilitation care in order to safely participate in therapy.
The Plan 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 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 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 from and participate in additional physical therapy and occupational therapy, but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
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 medically necessary.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteopenia with no history of an osteoporotic fracture. She has not tried and failed the plan's required drug of zoledronic acid. The records do not support that the required drug would be less effective or contraindicated; therefore, Prolia is not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from September 10, 2019 through September 11, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from September 10, 2019 through September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve grab bars, a raised toilet seat, and a tub bench.You asked the Plan to pre-approvethe grab bars, raised toilet seat, and tub bench. You say that the enrollee has impaired balance and impaired endurance. You say that the enrollee has generalized weakness and pain. You say that the enrollee is at high risk for falls and has poor safety awareness. You say that these things impact the enrollee's performance of functional tasks safely and independently.The Plan denied your request. The Plan says the items being requested are not primarily medical in nature.The Plan covers all items that Medicare covers. Medicare rules state that grab bars, raised toilet seats, and tub benchesare not covered because they are not primarily medical in nature. While grab bars, a raised toilet seat, and a tub benchmay be appropriate in this case, neither the Plan nor Medicare offers coverage of theseitems.Therefore, we decided that the Plan does not have to pre-approvegrab bars, a raised toilet seat, and a tub bench.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond March 22, 2020.
You asked the Plan to pre-approve the continued inpatient care. You say that more care in the inpatient setting would be beneficial. The Plan denied your request. The Plan says the enrollee is stable and can be managed in a less restrictive setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continued inpatient care. Our reviewer says that the continued inpatient mental health care is not shown to be reasonable and necessary beyond the date in question. Our physician reviewer found this 52-year-old male was admitted to the acute inpatient psychiatric hospitalization on March 16, 2020 with Bipolar Disorder Depressed, Generalized Anxiety Disorder, PTSD and Alcohol Use Disorder Severe. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors or unsafe behaviors. This patient was compliant with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, delusions or hallucinations or abnormal behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any illusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question.
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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond March 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic blood pressure monitor provided on November
9, 2019.
You asked the Plan to pay for the automatic blood pressure monitor. The Plan denied your request. The Plan
says that this is not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension.
The records do not show that this monitor is requested in the setting of home dialysis services, or that this
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.
Therefore, we decided that the Plan does not have to pay for the automatic blood pressure monitor provided on
November 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic images (D0350 x4) provided on November 5, 2019.
You asked the Plan to pay for the 2D oral/facial photographic images. The Plan denied your request. The Plan says this service is not a covered benefit
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic images (D0350 x4) provided on November 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee has a number of health issues. The Plan denied your request. The Plan says the admission is not medically necessary.
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 pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on March 22, 2020 for evaluation after a fall. She received oral medications and was treated for congestive heart failure and possible pneumonia. She received physical, occupational, and speech therapy in the hospital. She is modified independent with walking 40 feet with a rolling walker. She has no skilled nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you called 911 because you felt like you
were going to pass out. You say that you did pass out after the EMS responders arrived, and they proceeded to
check your vitals. They said your vitals were okay and asked if you wanted to be taken to the hospital. You
declined since you felt okay and wanted to save some money. You say that if you had known that the
ambulance would be not be covered without transport, you would have let them take you. You stated that you
thought you were saving everyone money and you do not think it is fair that you were not told otherwise. The
Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on September 6, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 13, 2019
through September 15, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting
physician reasonably expected that the patient's necessary hospital care (including earlier emergency
department (ED) and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from September 13, 2019 through September 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance service (A0428) ground
mileage (A0425) provided November 1, 2019.
You asked the Plan to pay for the ambulance service. You say that this enrollee is enrolleed in a PPO plan and
should be covered and does not require authorization. The Plan denied your request. The Plan says ambulance
transportation to or from a physician's office is not a covered destination.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance service
(A0428) ground mileage (A0425) provided November 1, 2019.