Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve the requested destination to the enrollee's doctor's office using the 
Plan's transportation benefit. 
 
You asked the Plan to pre-approve the requested destination to the enrollee's doctor's office. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the requested 
trip to the enrollee's doctor's office is 53.1 miles from the enrollee's home address, which exceeds the 50 mile 
per trip limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers 48 one-way transportation trips per calendar year, not to exceed 50 miles of driving 
distance per one-way trip. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for coverage of routine transportation have been met. In completing a google map search, 
the enrollee can reach the requested destination in 48 miles by avoiding highways. This meets the Plan's benefit 
criteria. Therefore, we decided that the Plan has to pre-approve the requested destination to the enrollee's 
doctor's office using the Plan's transportation benefit.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0220, D6103, D7140, D2999).

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the claim processed correctly.

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 services are either not among those covered under this benefit or are subject to a cost share responsibility. The Plan paid for dental codes D0220 and D7140. However, you are responsible for a 20% coinsurance for these services. Dental code D0220 is only covered once every 12 months. Since the Plan paid for this code once on this claim, the second x-ray exceeds the benefit limit and is not covered. Dental codes D6103 and D2999 are not covered services under your dental plan. Please note that the Plan approved payment for dental code D0140 in the amount of $15. Therefore, we decided that the Plan does not have to pay for the dental services (D0220, D6103, D7140, D2999).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says services can be provided at a lower 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 pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found no required skilled nursing services are identified. While you may benefit from skilled therapy services, the documentation does not support that continued skilled services are necessary on a daily basis in an inpatient facility. You do not require skilled nursing or therapy services on a daily basis on an inpatient level in the SNF. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating hospital.

You asked the Plan to waive the copayment for a CT scan. You say that you think this copayment is too high. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for outpatient diagnostic tests/in-network/advanced imaging services/outpatient hospital.

You have been asked to pay a $275 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests/in-network/advanced imaging services/outpatient hospital 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 copayment for a CT scan provided by a participating hospital.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of admission to skilled nursing facility from an inpatient rehabilitation facility (IRF) does not meet the requirements for approval.

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 medically necessary. Our physician reviewer found that the enrollee has stabilized medically and has been receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF). The enrollee no longer requires daily skilled nursing and/or skilled therapy services. The enrollee could benefit from continued intermittent services at a lower level of care. Although the enrollee made slow progress with therapy, her functional improvement has plateaued and there is no indication that transfer to a skilled nursing facility is required. The enrollee can continue to receive skilled rehabilitation services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an IRF. Admission to a SNF for inpatient skilled rehabilitation services 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular stress test rendered on September 19, 
2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 93016 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93016 is cardiovascular stress test using maximal or 
submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological 
stress; supervision only, without interpretation and report. 
 
We find that CPT code 93016 is not supported in the medical record. Specifically, there is no documentation of 
a cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise. 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 pay for the cardiovascular stress test rendered on September 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 
laboratory services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services coded 99307 
provided on July 12, 2019. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99307 
for the subsequent nursing facility care services has a bundled relationship with code 36465 and cannot be paid 
as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent nursing 
facility care services coded 99307 provided on July 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the
expectation the enrollee will require a greater than 2 midnight stay.

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 pre-approve inpatient hospital services. Our
reviewer says that that inpatient hospital services are not medically reasonable and necessary for the enrollee.
The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure.
The planned procedure listed under CPT code 27447 is not listed on the CMS Inpatient Only List. The
arthroplasty procedure is currently approved as an ambulatory outpatient procedure. Our physician reviewer
found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on October 26, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
psychotherapy services. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on  
October 26, 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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for Osteomyelitis, gangrene and peripheral vascular disease. You had right leg amputation, subsequently revised to right below the knee amputation. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services.

You asked the Plan to pay for the dental services. You say that your online benefit statement stated you had one remaining examination for calendar year 2020. The Plan denied your request. The Plan says you had already exceeded your benefit allowance for the requested services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services exceed those covered under this benefit. The Plan has submitted evidence that you received oral evaluations. Therefore, we decided that the Plan does not have to pay for the dental services.

Your complaint about your online benefit statement indicating you had one remaining oral evaluation for the calendar year is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care for a right reverse total shoulder arthroplasty.

You asked the Plan to pre-approve the acute inpatient hospital care. You say that inpatient hospital care is medically necessary for this surgery. The Plan denied your request. The Plan says inpatient hospital care 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 pre-approve the acute inpatient hospital care. Our reviewer says that acute inpatient hospital care is not medically necessary. Our physician reviewer found that under Medicare rules, an inpatient admission is generally appropriate if the patient requires medically necessary hospital care that is expected to span two or more midnights. This includes time spent in the emergency department (ED) and/or observation, as well as time spent at another hospital prior to transfer to the current facility. The decision to admit as an inpatient should generally be based on the treating physician's reasonable expectation of a length of stay spanning two or more midnights, taking into account complex medical factors that must be documented in the medical record. In this case the documentation does not indicate that you, as the treating physician anticipated the need for an inpatient admission nor provides the support for why an inpatient stay would be required. Therefore, the elements of the Medicare rule are not satisfied and the requested service cannot be recommended.

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 acute inpatient hospital care have not been met.

Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care for a right reverse total shoulder arthroplasty.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says it is feasible to meet your medical needs at a lower 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 pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and have been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). You no longer require daily skilled nursing and/or skilled therapy services. You could benefit from continued intermittent services at a lower level of care. Although you made slow progress with therapy, your functional level has plateaued, and there is no indication that transfer to a skilled nursing facility is required. You can continue to receive skilled rehab services at the current IRF, or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy.

You asked the Plan to pre-approve Proton Beam Radiation Therapy. You say that the enrollee wants this treatment. The Plan denied your request. The Plan says the determination and payment for this trial is not up the Plan but to Medicare.

The Plan must follow Medicare rules. Medicare rules say that Medicare approved clinical trials and certain procedures that are part of the clinical trials program can be covered by traditional Medicare, but they are not covered by the health plan. 

We looked at the file and Medicare rules. Clinical trials are not covered by health plans. Based on this information, we decided that Medicare rules for coverage of Proton Beam Radiation Therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy.