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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee lives alone in a second-floor apartment, and IRF service would provide the enrollee with close physician supervision which would allow for a quick turnaround.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. While the enrollee may benefit from and participate in additional therapies of physical therapy and occupational therapy, the enrollee does not require this on an intensive rehabilitation therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nursing facility care (99490) provided  on November 30, 2019. You asked the Plan to pay forthe nursing facility care. You say that services were medically necessary.The Plan denied your request. The Plan says services were not emergent or preauthorized. There were network providers who could provide the services at issue.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 forthe nursing facility care (99490) provided  on November 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 16, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered to the enrollee on April
16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay formolecular pathology services provided on April 12, 2019 by an out of network (OON) provider.You asked the Plan to pay formolecular pathology services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan says that no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 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 hasnetwork providers available who can provide 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 thatthe Plan does not have to pay formolecular pathology services provided on April 12, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve cellular function assay testing provided by Hospital on September 23, 2019.You asked the Plan to pre-approve laboratory test. You say that the documentation clearly shows medical necessity.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is experimental or investigational.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 laboratory test. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found it is medically appropriate to check the chronic urticaria index or Immuneglobulin-E (IgE) antibodies in an individual with the enrollee's condition. This test has been demonstrated to distinguish between autoimmune mediated disease versus those that are not. In addition, it has also been shown to be a possible marker of disease severity and a means by which to determine response to the drug omalizumab.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laboratory test have been met.Therefore, we decided that the Plan has to pre-approvecellular function assay testing provided by Hospital on September 23, 2019.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-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. 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 LTACH services are covered if theyare 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 the documentation does not support that the enrollee in this caserequires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, andMedicare 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-approvelong term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided by an out
of network (OON) provider on March 26, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment of the services provided. The Plan denied your request. The Plan says services rendered by
nonparticipating providers require prior authorization. The Plan did not authorize any services for the facility or
the treating practitioner. The services provided are not considered urgent or emergent in nature.
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 provider nor the facility in this case are network providers with the Plan. The Plan has network providers
available who can provide 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 subsequent nursing facility care (99308) provided on March 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Bone Density Scan provided on October 31, 2019. You asked the Plan to pay forthe Bone Density Scan. You say that services were medically necessary.The Plan denied your request. The Plan says the services were not preauthorized and there were network providers available.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 has network providers available who can provide 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 forthe Bone Density Scan provided on October 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF 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 above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and applythe 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 provided medical records do not indicate a need for daily skilled services or inpatient services. Care in a nursing facility at a custodial level of care with intermittent therapy services as needed appears to be appropriate.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-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.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 based on the provided medical records the enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health 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 notbeen met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 23, 2019.You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this was a necessary service.The Plan denied your request. The Plan says payment of this service is included in the DRG payment.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 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 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.Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 CFR 422.101.
The rules say that Medicare will pay for acute inpatient hospital services when:
1. The patient's signs and symptoms and general medical condition can only be managed safely in an
acute inpatient setting,
2. The enrollee requires diagnostic studies in an inpatient setting, or
3. It is medically necessary for the enrollee to remain in the acute inpatient setting.
The doctor responsible for a patient's care is responsible for deciding whether the patient should be admitted as
an inpatient. Doctors should use a 24-hour period as a benchmark. This means they should order admission for
patients who are expected to need hospital care for 24 hours or more, and treat other patients on an outpatient
basis. You can find this rule in the Medicare Benefit Policy Manual, Chapter 1, Section 10.
The rules define observation services as outpatient services which include ongoing short-term treatment,
assessment, and reassessment. During observation, the doctor will decide whether to discharge a patient from
the hospital or admit the patient as an inpatient. You can find these rules in the Medicare Benefit Policy
Manual, Chapter 6, Section 20.6.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from August 14, 2019 through August 20, 2019.You asked the Plan to pay forinpatient hospital care. You say that the claim should be paid.The Plan denied your request. The Plan says the stay is not medically necessary.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 inpatient hospital care. Our physician reviewer found the review has determined that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a plan facility for observation/admission level of care services. There was no documentation provided necessitating post-stabilization care services beginning August 14, 2019 at the non-participating facility. Post-stabilization are services at thenon-participating facility were not medically necessary and reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.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 care have not been met.Therefore, we decided that the Plan does not have to payforinpatient hospital care provided to the enrollee from August 14, 2019 through August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on October 10, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 andpre-approved care.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. The Plan did not pre-approve the services at issue. We found noexception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on October 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process
stabilization/distraction device (22867).
You asked the Plan to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction
device. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for
coverage have not been met.
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 the insertion of
interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services
are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is
experimental. More research is needed before it can be considered 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 insertion of interlaminar/interspinous process stabilization/distraction device
have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of
interlaminar/interspinous process stabilization/distraction device (22867).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe mammogram (77067,  77063)  provided on April 29, 2019.  You asked the Plan to pay forthe mammogram. You say that the screening mammogram should be covered.The Plan denied your request. The Plan says screening mammograms are only covered when received from an in-network provider.Medicare rules say that plans can require enrollees to get care fromnetwork 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 has network providers available who can provide 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 forthe mammogram (77067,  77063)  provided on April 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forresin-based composite -two surfaces, anterior (D2331), resin-based composite -three surfaces, anterior (D2332) and resin-based composite -one surface, anterior (D2330) provided on September 26, 2019.You asked the Plan to pay forthe dental services. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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.The Plan confirmed that you had procedure D2331 completed on tooth #7, 8, 9, 10, 11 and 23 and you had a copayment of $75 for each of them respectively. They confirmed that you had procedure D2332 completed on tooth #24 which had a copayment of $85. They confirmed that you also had procedure D2330 completed on tooth # 25, 26 and 27 with $65 co-payment for each of the tooth respectively.  The total copayment for the completed composite filings that you are financially responsible for is $730. Since the amount $730 isyou share of cost, it will not be refunded. You paid $1140 to the dental office, DeltaCare agreed to refund $410 back to you due to over-payment.Therefore, we decided that the Plan does not have to pay forresin-based composite -two surfaces, anterior (D2331), resin-based composite -three surfaces, anterior (D2332) and resin-based composite -one surface, anterior (D2330) provided on September 26, 2019.