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

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond March 16, 2021.
You asked the Plan to pre-approve the continued inpatient psychiatric care. You say that it is felt that continued inpatient management is medically necessary. The Plan denied your request. The Plan says the records do not show that active treatment is taking place beyond March 16, 2021.
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 psychiatric care. Our reviewer says that the documentation does not support that the Medicare medical necessity criteria are met beyond the date in question. Our physician reviewer found the enrollee was admitted to an inpatient psychiatric unit on 3/8/21 when she was demonstrating erratic, aggressive behavior including physical violence toward others. The enrollee's family felt that they could no longer care for her. The enrollee was started on olanzapine. Geodon was administered intramuscularly as needed. As of 3/16/2021, no neurological/psych symptoms were reported. The enrollee was calm and confused. The plan was to continue hospitalization and maintain a safe environment. Beyond the date in question, there was no clear expectation that this enrollee would improve in a reasonable period of time. It is not demonstrated that continued inpatient services were reasonably expected to improve the patient's condition or aid in diagnosis. It is not medically necessary for the enrollee to have psychiatric care provided at the inpatient level rather than 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 continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond March 16, 2021.
Appeal type: Practitioner Services
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on October 19, 2020, through October 23, 2020.
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says procedure code 27486 is listed as an inpatient procedure.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 27486. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Of note, all remaining lines were either rejected by the Plan for services not separately payable or denied for services on same day as inpatient procedure. Therefore, we decided that the Plan does not have to pay for the outpatient services provided on October 19, 2020, through October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve behavioral health services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON services. You say that the in-network provider does not have an available appointment for two months. The Plan denied your request. The Plan says you will need to continue care with 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve additional behavioral health 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 pre-approve pain management services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON pain management services. The Plan denied your request. The Plan says the one transition-of-care visit that they have approved is sufficient and that further OON care is not medically necessary.
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 pain management services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on April 29, 2019.
You asked the Plan to pay for the services provided. You say that you depend on the facility for timely notification of the enrollee's insurance coverage. The Plan denied your request. The Plan says the claim was received past the allowed timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a clean claim for the services provided was not filed until October 8, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the physician services provided on April 29, 2019.
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 admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services. This enrollee does require skilled therapy services; however, daily skilled services are not required. This enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF 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: 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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 23, 2021 for a dental abscess. He has a chronic tracheostomy and feeding tube placed from his stroke three months prior. The was intubated on February 27, 2021. 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. 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: 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 SNF services. You say that SNF 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 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records do not show that you require skilled nursing or therapy services on a daily basis. The records do not show your condition meets a severity of illness or intensity of service criteria for 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 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: Favorable

We decided that the Plan has to pre-approve continued inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that continued inpatient skilled nursing facility care is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of continued inpatient skilled nursing facility care.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide the medical records that pertain to this case. Therefore, we decided that the Plan has to pre-approve continued inpatient skilled nursing facility (SNF) care. The plan must continue to cover these services until the 100-day benefit is exhausted or proper notice is issued.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services beginning March 30, 2021.
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.
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the records show that you were admitted to the hospital on March 23, 2021 with Type I bipolar disorder. Based on the records, you are not expected to improve in a reasonable period of time, as you do not have suicidal or homicidal ideation and no auditory or visual hallucinations. You are cooperative with care and not showing dangerousness to self or others. The services are not expected to improve your condition or for the purpose of diagnosis. Continued inpatient psychiatric services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services beginning March 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for unilateral breast ultrasounds (76642) provided on September 17, 2020.
You asked the Plan to pay for unilateral breast ultrasounds. You say that the records support separate services. The Plan denied your request. The Plan says the records do not support the units billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 4 units of CPT code 76642 are not supported in the medical record. The medical record only supports 2 units of CPT code 76642. Based on this information, we decided that Medicare rules for coverage of unilateral breast ultrasounds have not been met. Therefore, we decided that the Plan does not have to pay for unilateral breast ultrasounds (76642) provided on September 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the toric lenses provided on May 29, 2020, and June 5, 2020.
You asked the Plan to pay for the provided lenses. You say that your eyes were always strained. The Plan denied your request. The Plan says non-conventional lenses are not covered.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the toric lenses provided on May 29, 2020, and June 5, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva for the enrollee.
You asked the Plan to pre-approve Xgeva. You say that Xgeva is medically necessary. The Plan denied your request. The Plan says the required step therapy criteria are not met.
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 Xgeva. Our reviewer says that the required step therapy requirements are not met. Our physician reviewer found the documentation does not support that pamidronate would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services.

You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says this is maintenance therapy.

The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care.

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 chiropractic services. Our reviewer says that the requested chiropractic services are considered maintenance therapy. Our physician reviewer found that there is no evidence that clinical improvement has or will likely improve from continuous ongoing chiropractic care. The chiropractic treatments are maintenance therapy and are not supported or allowed per Medicare guidelines.

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 chiropractic services have not been met. Therefore, we decided that the Plan does not have to pay for the chiropractic services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the medical services provided on October 28, 2020.
You asked the Plan to waive the copay for the services provided. You say that you paid a specialist copay despite the copay being waived. The Plan denied your request. The Plan says the cost share waiver does not include labs, x-rays or other tests.
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 $20 copay per visit for non-radiological diagnostic tests. The file shows that you received a routine electrocardiogram. You were charged $16.16 for the services. Because the amount is less than the $20 copay, you were charged the lesser amount. The services fall within the outpatient diagnostic tests 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 copay for the medical services provided on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on December 2, 2020.
You asked the Plan to pay for the prophylaxis. You say that you feel that this third cleaning should be covered because you purchased the additional dental coverage. The Plan denied your request. The Plan says the maximum coverage for this service has been met for the 2020 plan year.
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 are limited to up to two routine cleanings per calendar year. The record shows that you received a prophylaxis on February 26, 2020, and July 8, 2020 and your prophylaxis benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on December 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the Home Health Aide services (G0156) provided on June 22, 2020, through June 26, 2020.
You asked the Plan to pay for the Home Health Aide services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of note and time was not documented.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.
The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in this appeal. Additionally, the documentation submitted did not include any record of the services billed. Of note, it does not appear that this provider is eligible for Medicare. Therefore, we decided that the Plan does not have to pay for the Home Health Aide services (G0156) provided on June 22, 2020, through June 26, 2020.