Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for care in an LTACH. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval of LTACH care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found 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 she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the durolane injection provided on January 25, 2021.

You asked the Plan to waive the coinsurance for the durolane injection. You say that you told the doctor you didn't need a shot because you needed surgery. You say that you were told you did not have to pay anything other than your $35 co-payment. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the plan-allowed amount for Medicare Part B-covered drugs from an in-network provider.

You have been asked to pay $200.88, which is 20% of the allowed amount for the durolane injection. The allowed amount is $1,004.40 (20% x $1,004.40 = $200.88). The durolane injection falls within the "Medicare Part B prescription drugs" 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 the durolane injection provided on January 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care, for the enrollee.

You asked the Plan to pre-approve SNF 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This beneficiary enrollee does not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care, for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 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 SNF care. 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 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. The enrollee 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on July 29, 2020.You asked the Plan to pay for critical care services. You say that this is supported in the records.The Plan denied your request. The Plan says this is not documented.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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent on critical care services is not documented in the records. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met.Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on November 16, 2020.

You asked the Plan to pay for the crown. You say that you feel that your claim was processed incorrectly. The Plan denied your request. The Plan says your dental reimbursement maximum has been met.

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 Plan offers a $1,000 dental allowance every year for Non-Medicare covered preventive and comprehensive dental services combined. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while processing this claim for the November 16, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the crown provided on November 16, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 7, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit,through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for physician's services provided on October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the fluoride varnish (D1206) received January 12, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and the fluoride varnish. You say that the requested services should be paid by the Plan. The Plan denied your request. The Plan says there is a frequency limitation for comprehensive oral evaluations, and fluoride varnish is not covered under your supplemental 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. The Plan has submitted evidence that a claim was paid for a
comprehensive oral evaluation on June 3, 2020. When you received this procedure on January 12, 2021, your benefit was exhausted. Your supplemental benefit with the Plan does not include fluoride varnish. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the fluoride varnish (D1206) received January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lenses provided on December 24, 2020.

You asked the Plan to pay for the contact lenses. The Plan denied your request. The Plan says the vision benefits do not include out-of-network coverage.

Medicare generally does not cover routine eye wear services. However, the Plan offers a routine eye wear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received from a participating provider.

We looked at the file and the Plan's rules. The file shows that the contact lenses were not received from a participating provider.

Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for contact lenses provided on December 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips (A0100).You asked the Plan to provide additional transportation. You say that you have no other means of transportation available, and you need additional trips to see your specialist.The Plan denied your request. The Plan says you have exhausted the maximum number of routine transportation trips covered by the Plan. Additional transportation cannot be provided.
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 a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to provide additional routine transportation trips (A0100).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, per diem, provided from December 30, 2020, to January 4, 2021.

You asked the Plan to pay for the home health service. You say that the services were medically necessary. The Plan denied your request. The Plan says the code at issue in this case is invalid for usage with Medicare. The Plan also says that the Medicare rule for payment of this claim has not been met.

The Plan must follow Medicare rules. Medicare rules say that procedure code S9502 - Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, per diem - has a Status Code of "I", indicating that this code is not valid for Medicare purposes and is not payable. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health service have not been met. Therefore, we decided that the Plan does not have to pay for Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, per diem, provided from December 30, 2020, to January 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
November 25, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided by multiple out-of-network
providers from July 26, 2019, through October 17, 2019.

You asked the Plan to pay for the medical services. The Plan denied your request. The Plan says the enrollee
should receive all available covered services from plan providers. In the event that covered services are not
available in-plan, the Health Plan will refer the enrollee to a designated community 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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested providers in this case are not a network providers with the Plan. The Plan did not pre-approve
the services at issue. We found no exception that would require the Plan to pay for these services.

Therefore, we decided that the Plan does not have to pay for medical services provided by multiple out-of-network providers from July 26, 2019, through October 17, 2019.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure services coded 97110 provided on
December 24, 2020.
You asked the Plan to pay for the therapeutic procedure services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 97110 is therapeutic procedure, 1 or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows
that these services were performed by a physical therapist assistant in a home health or hospice setting. A more
appropriate code should be billed for these services provided. Based on this information, we decided that
Medicare rules for coverage of the therapeutic procedure services have not been met. Therefore, we decided
that the Plan does not have to pay for the therapeutic procedure services coded 97110 provided on December
24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewings -two radiographic images (D0272) provided August 31, 2020.You asked the Plan to pay for the comprehensive oral exam and bitewing x-rays. You say that your wife was told that the services would be covered by this provider.The Plan denied your request. The Plan says the dentist who provided the services is out-of-network and therefore the services 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 comprehensive oral exam and bitewing x-rays when the services are provided by a network provider.
We looked at the file and Medicare rules. 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.Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral exam and bitewing x-rays have not been met.Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewings -two radiographic images (D0272) provided August 31, 2020.