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

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve physical therapy. You say that you have tried to contact in-network
providers but were advised that they do not do amputee therapy. The Plan denied your request. The Plan says
the denial of authorization for these services 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. 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
physical therapy 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 pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is 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 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 you do not meet Centers for Medicare & Medicaid Services (CMS) criteria for
coverage for an IRF admission. You are generally medically stable despite complex history after right femoral
fracture and status post open reduction and internal fixation (ORIF) six (6) months ago. You had pain but no
other complications noted. Documentation does not support any evidence of complex medical issues that
require monitoring (except pain which is an outpatient level of care) by an inpatient physical medicine and
rehabilitation (PMR) physician three (3) times per week.

There are no acute rehab nursing needs. Functionally as described above still dependent for activities of daily
living (ADLs) and mobility after 6 months of therapies. While you may benefit from continuing physical
therapy (PT) and occupational therapy (OT), there is no evidence of need for an intensive therapy program with
therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation
care. IRF admission is not medically necessary based on lack of medical complexity. Your rehab needs can be
easily and safely met at an alternate and less intense level such as in a skilled nursing facility (SNF) 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140)
provided February 5, 2021.

You asked the Plan to pay for limited oral exam. You say that there has been a lot of confusion with your
dental coverage. The Plan denied your request. The Plan says this service is not covered under your dental
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 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
limited oral evaluation - problem focused (D0140) provided February 5, 2021.
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 can remain in the current acute care location until such time no further acute level care is needed.
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. As acute care hospitals and LTACHs are licensed to provide the same level of care, there is no advantage in moving the member from the current acute care hospital to an Long Term Acute Care Hospital (LTACH). There is no documentation provided necessitating admission to a LTACH. 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/she 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post stabilization care provided from November 1, 2020,
through November 3, 2020.
You asked the Plan to pay for the inpatient admission. You say that the inpatient admission was provided in
good faith and you provided the complete medical records and billing details for review. The Plan denied your
request. The Plan says the enrollee's emergency medical condition stabilized by 8:30 p.m. on
November 1, 2020 and subsequent care was post stabilization care, which is not approved in compliance with
the health Plan's authorization procedures. The Plan has paid for all emergent care up to the point of stability.
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 inpatient admission. Our reviewer says
that the post stabilization care does not meet Medicare criteria. Our physician reviewer found that the enrollee
is a 76-year-old female with degenerative cervical arthritis and a history for significant episodes of vertigo who
was admitted to the hospital for telemetry after a fall related to sudden neck pain and dizziness. The
documentation does not show that the enrollee was unstable as documented by the treating physicians. Based
on the documentation, the enrollee appeared to be stable for transfer by ambulance to an in-network hospital at
8:30 p.m., on November 1, 2020.
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 inpatient admission have not been met. Therefore, we decided that the Plan
does not have to pay for post stabilization care provided from November 1, 2020, through November 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been 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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. You do require physical and occupational therapy but there is no documented
need for an intensive rehabilitation program. Medically necessary services can be provided in a different level
of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care beginning on July 28, 2021.

You asked the Plan to pre-approve inpatient mental health care. You say that this is medically necessary. The
Plan denied your request. The Plan says the enrollee does not require inpatient care at this time.

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 inpatient mental health care. Our
reviewer says that the requirements for coverage of continued inpatient care are no longer met. Our physician
reviewer found it is not expected this enrollee would improve in a reasonable period of time as she does not
have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations.

The patient has been compliant with treatment while not showing any acute threats to safety. It does 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 last approved date.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient mental health care beginning on July 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes (CPT code G0151 X8), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee has completed sixty (60) days of home care physical therapy. The Plan states the enrollee is trained and able to do the home exercise program, an assessment for a knee replacement is planned, there is no record of progressive neuromuscular disorder, progressive dementia or cystic fibrosis and continued gains can occur with the home exercise program.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 physician reviewer found the health plan's denial should be upheld. The enrollee appears to be functioning at a level that no longer requires regular skilled physical therapy (PT). As such, ongoing home health (HH) PT is not medically necessary or reasonable. 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 eight (8) services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes (CPT code G0151 X8), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 5, 2020, to December 31, 2020.

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's condition no longer required daily skilled services at an inpatient SNF level of care.

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 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. 

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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from December 5, 2020, to December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) received March 16, 2021.
You asked the Plan to pay for the panoramic radiographic image. You say that you were new to this dentist's office and were told all services would be covered. The Plan denied your request. The Plan says there is no coverage for panoramic radiographic images.
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 panoramic radiographic image (D0330) received March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services (Q3014) provided on April 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the telehealth services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the telehealth services (Q3014) provided on April 26, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an oncologist not in your primary network.
You asked the Plan to pre-approve these services. You say that you are entitled to a second opinion. The Plan denied your request. The Plan says the services are available from an oncologist within your primary network.
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 provider within your primary network. The Plan has providers in your primary network 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 a referral to an oncologist not in your primary network
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in
the setting of spinal stenosis has not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Detailed
documentation is not evident regarding at which levels and what type of discogenic endplate changes are
demonstrated on MRI. Furthermore, additional (plausible pain-generating) pathology is demonstrated on the
MRI at L4-5. This includes a broad-based disc bulge (6mm) which in conjunction with facet hypertrophy,
ligamentum flavum laxity, and grade 1 anterolisthesis contribute to severe central narrowing moderate to
severe right and moderate to severe left foraminal narrowing, all worse in particular the central narrowing at
the requested procedure level of L4-5. There is also a 35-degree scoliotic curve (with apex at L3). Therefore,
multiple other plausible pain generators including at the lumbar/lumbosacral spine are evident.
Specific basivertebral nerve(s)/vertebrogenic pain is not fully and/or reasonably identified as the only and/or
clear primary source of pain. Furthermore, there is limited published, large-scale, long-term peer-reviewed
literature that shows the request to be an effective and/or safe treatment for the noted pathology. Our physician
reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided March 17, 2021.

You asked the Plan to pay for the orthoses. You say that please review this claim due to the current COVID-19 pandemic guidelines and reconsider accordingly. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician. The provider is not a Medicare certified DME supplier and not eligible to receive payment.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on
February 2, 2021.
You asked the Plan to waive the coinsurance for radiation therapy services. You say that you could have done
surgery for free but was advised of radiation treatment. You say that you were never told there was 20%
coinsurance. The Plan denied your request. The Plan says the coinsurance applied correctly.
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 20%
coinsurance per visit for radiation therapy.
You have been asked to pay $108.86, which is 20% of the allowed amount for radiation therapy services. The allowed amount is $544.29 (20% x $544.29 = $108.86). Radiation therapy services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on February 2, 2021.