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

We decided that the Plan does not have to pay for critical care services provided on September 1, 2020.

You asked the Plan to pay for the critical care services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no documentation supporting this service.

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, there are no medical notes in the case file for this date of service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services provided on September 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need therapy to regain maximum functioning ability. The Plan denied your request. The Plan says you do not require an intensive and coordinated interdisciplinary approach to rehab.
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 physician reviewer found that you were admitted to the acute care hospital for atrial fibrillation. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehab therapy program.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on February 1, 2021.

You asked the Plan to waive the copayment for a CT scan. You say that you were told that you would only owe
$127.41. The Plan denied your request. The Plan says the claims were processed correctly and you are being
charged the correct amount.

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 $180
copayment for advanced imaging services provided at a freestanding radiological facility.

You have been asked to pay the allowed amount of $136.37, which is less than the $180 copayment for a CT
scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for a CT scan provided on February 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are
medically necessary. The Plan denied your request. The Plan says that current care appears to be more chronic
in nature and more non-acute behavioral health inpatient services.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the
enrollee. It is not expected that the enrollee would improve in a reasonable period of time as he does not have
dangerousness to self or others, auditory or visual hallucinations, delusions and is not showing any behavioral
issues. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute
inpatient level of care rather than a lower level of care as he does not have dangerousness to self or others,
perceptual disturbance including auditory or visual hallucinations. Our physician reviewer found that the
enrollee's condition does not meet Medicare criteria for inpatient psychiatric 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 psychiatric hospital services have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is at high risk for falls. The Plan denied your request. The Plan says the enrollee is not able to participate in 3 hours of intensive therapy 5 days a week.
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 physician reviewer found that the enrollee has a past history of stroke, atrial fibrillation, and diabetes. She was recently seen in acute care for a deep vein thrombosis. She was discharged back to skilled nursing facility after the acute care visit. Her medical conditions are stable. There are no complex nursing needs. There is not a reasonable expectation that she will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. She does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a nonstandard seat frame width, 20-23 inches and a nonstandard seat frame depth, 20 or 21 inches.
You asked the Plan to pre-approve a nonstandard seat frame width, 20-23 inches and a nonstandard seat frame depth, 20 or 21 inches. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the services are not covered.
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. The Plan's only denial rationale for the requested items is the nonstandard seat frame width, 20-23 inches being represented by code E2340 and the nonstandard seat frame depth, 20 or 21 inches being represented by code E2342 as being invalid codes. However, Medicare says these codes are only invalid if submitted on a claim for payment. As this is a prior authorization request, the Plan's reasoning for denial based on a CPT code is not valid. This is not a claim submission denial, as there is no claim. Therefore, we decided that the Plan has to pre-approve a nonstandard seat frame width, 20-23 inches and a nonstandard seat frame depth, 20 or 21 inches.
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 acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require an
intensive multidisciplinary approach to daily therapy.
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 physician reviewer found
that you were admitted to the acute hospital for weakness, hematuria and a urinary tract infection. Your
medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple
therapies in an intensive rehabilitation therapy program. You do require physical and occupational therapy but
there is no documented need for an intensive rehabilitation program.
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a sacroiliac joint injection (G0260).
You asked the Plan to pre-approve a sacroiliac joint injection. You say that this injection would benefit the
enrollee. The Plan denied your request. The Plan says that the enrollee has not failed conservative therapy.
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 a sacroiliac joint injection. Our
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our
physician reviewer found the patient has positive physical exam findings that support the diagnosis of left
sacroiliitis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a sacroiliac joint injection have been met. Therefore, we decided that the Plan
has to pre-approve a sacroiliac joint injection (G0260). 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 reline of a mandibular partial denture provided on March 15, 2021.
You asked the Plan to pay for the reline of a mandibular partial denture. You say that the providers office advised that this service would be fully covered, prior to this service being rendered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Your contract only provides coverage for relines of complete dentures. Therefore, we decided that the Plan does not have to pay for the reline of a mandibular partial denture provided on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of the torus mandibularis (D7473 x 2).
You asked the Plan to pre-approve the dental services. You say that this service is necessary for you to get dentures. You say that you have no remaining teeth. You also say that this is detrimental to your health. The Plan denied your request. The Plan says removal of the torus mandibularis is not listed as a covered service.
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, removal of the torus mandibularis not among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pre-approve removal of the torus mandibularis (D7473 x 2).
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 you were admitted to the hospital on May 30, 2021 after a motor vehicle collision. You are is receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require 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 your diagnosis and condition 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan denied your request. The Plan says the requested Prolia is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Prolia. Our reviewer says that the requested Prolia is not medically necessary. Our physician reviewer found the enrollee is diagnosed with age-related osteoporosis without current pathological fracture. Criteria for Prolia not met. There is no documentation of first line drug use for osteoporosis. More information is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 22 additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that authorization was denied and the clinicals should be reviewed for reopening. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. Our physician reviewer found the patient was already approved for 18 more visits which is enough to ensure competence in a home exercise program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 22 additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta.
You asked the Plan to pre-approve Neulasta. You say that the requested Neulasta is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Zarxio first.
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 Neulasta. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with small cell lung cancer who is receiving myelosuppressive chemotherapy. Neulasta injections have been requested due to the risk of neutropenic fever. The health plan denied coverage for the Neulasta as the plan requires a trial of Zarxio before they will approve the requested drug. Based on the medical records provided the enrollee has not tried and failed the required drug(s). Based on the medical records provided there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta.
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 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 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 medically necessary. Our physician reviewer found you were admitted to the hospital for hip surgery after a fall. You are now medically stable with 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.
You may benefit from further therapy but do not require an intensive therapy program in an IRF. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on February 23, 2021.
You asked the Plan to pay for the laboratory test. You say that the test is a covered service under the Medicare program for patients with indeterminate thyroid nodules. You say that the claim should be covered by the Plan at the set rate. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not 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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on February 23, 2021.