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

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee is a fall risk and has experienced several falls. You say that admission to a SNF would help strengthen the enrollee. The Plan denied your request. The Plan says that the records do not show that the enrollee needs daily skilled nursing care. The Plan says that the records do not show that the enrollee is able to do one or two hours of therapy per day, in her current state. The Plan says that the enrollee could receive the services needed in another care setting.
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 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 the criteria for coverage have been met. Our physician reviewer found the enrollee was status-post treatment for an impacted right femoral neck fracture. The enrollee required oversight of her medical conditions and medication management. She has cognitive impairment and would not be expected to be able to adjust medications or self-monitor her medical conditions. The enrollee has not returned to her prior level of function. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. The enrollee requires daily skilled therapy services. She was unable to perform essential activities of daily living such as bed mobility without assistance and was unable to transfer or ambulate. The enrollee's condition would be expected to deteriorate with services provided on a less than daily basis. The enrollee had previously been able to perform essential activities of daily living such as bed mobility and transfer without hands-on assistance. There was a reasonable expectation of a reduction in burden of care through the SNF level care being requested. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. You say that you believe you have something other than IBS and you would like another physician's opinion. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 the requested services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's 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 the SNF services. The Plan denied your request. The Plan says the enrollee is medically stable with no daily skilled needs.
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 apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require ongoing skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment after the last covered day. The enrollee does not have a tracheostomy tube, new enteral feedings, complex wound care or other SNF level skilled nursing need. The enrollee's functional level does not require ongoing skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF after the last covered day. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting after the last covered day.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-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 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 medical services provided to the enrollee by an out-of-network provider on August 29, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound examination provided on January 22, 2020.
You asked the Plan to waive the copayment for ultrasound. You say that this test should be covered in full with no copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $50 copayment for ultrasound exam performed by a specialist. You have been asked to pay $50 copayment for ultrasound. Ultrasound 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 an ultrasound examination provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that this was the only doctor that could see you before February 2020. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 for the medical services provided on December 16, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anterior cervical discectomy and fusion (ACDF) surgery.
You asked the Plan to pre-approve these services. You say that you have severe neck pain. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have neck pain with other cervical displacement. There is no documentation of a significant trial and failure of conservative treatments prior to surgery. There are no red flags for surgery. Based on the submitted records, the requested spine surgery is not reasonable or medically necessary at this time. 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 anterior cervical discectomy and fusion (ACDF) surgery.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the limited oral evaluation (D0140) provided on November 14, 2019.
You asked the Plan to pay for the dental service. You say that you have previously sent multiple claims from 2019, multiple times to the plan which have not been acknowledged. You say that the service you received on November 14, 2019 does not reflect the full picture of the dental services you received. You also say that you have paid more than $50 out of pocket for services that you received in 2019. The Plan denied your request. The Plan says that the deductible was applied correctly. The Plan says that the provider in this case is an in network provider. The Plan also says that the $50 in network deductible has not been reached.
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 did not substantiate their claim that nothing had been applied to the in network deductible prior to receiving the service on November 14, 2019. Without evidence of the amount of the in network deductible that remained, we are unable to determine if the correct amount was applied to the deductible for this date of service. Therefore, we decided that the Plan has to pay for the limited oral evaluation (D0140) provided on November 14, 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.
Your complaint about the Plan not processing your previous claims for 2019 is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says a lower level of care facility remains a suitable option for post-acute 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 you are currently undergoing treatment at an ACH. Initially treated for pneumonia, she was subsequently treated for bacterial peritonitis. You are not intubated/ventilated. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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 admission to a long-term acute care hospital (LTACH).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens, hydrophilic, spherical, per lens (V2520) and contact lens fitting (92310) provided on September 18, 2019.
You asked the Plan to pay for the services. You say that you believe that you should be reimbursed %55 for the lens fitting and $5 for the contact lenses. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The Health Plan benefit does provide maximum allowance of $75 for non-Medicare covered eyewear, including contacts. Therefore, the Health Plan has reprocessed and paid$ 75 for V2520 contact lenses. HCPCS code 92310, contact lens fitting, the service is not covered by Medicare per CMS guidelines.
Therefore, the Health Plan will continue to deny reimbursement for 92310, contact lens fitting as you have been reimbursed the maximum allowance for non-Medicare covered vision services and the appealed service is not covered by either Medicare or the Health Plan. Therefore, we decided that the Plan does not have to pay for contact lens, hydrophilic, spherical, per lens (V2520) and contact lens fitting (92310) provided on September 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission to an inpatient behavioral health facility.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the plan limit for inpatient psychiatric services is 190 days.
The Plan must follow Medicare rules. The rules say that there is a 190-day lifetime for inpatient psychiatric hospital services. The file shows that 190 day lifetime limit has been met. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve an admission to an inpatient behavioral health facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for specialty eyewear/Lens provided on December 5, 2019.
You asked the Plan to pay for the specialty eyewear/Lens. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says they were advised that you have a very high prescription and purchased high index lenses to avoid having thick lenses. The Plan states the provider is willing to remake them without the high index at no cost, however, you will have thick lenses. The Plan states you were given this information at the time of service.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Your plan covers standard eyewear after cataract surgery. The Plan does not cover enhanced upgrades to the standard eyewear such as lens options. You must get your eyewear from a medical provider. Therefore, we decided that the Plan does not have to pay for specialty eyewear/Lens provided on December 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy provided from December 17, 2019 to December 24, 2019.
You asked the Plan to pay for home infusion therapy. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not a valid code for Medicare purposes. S codes are unique temporary codes established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy provided from December 17, 2019 to December 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis provided on October 21, 2019.
You asked the Plan to pay for the wrist hand orthosis (L3916RT). You say that the orthosis is medically necessary. The Plan denied your request. The Plan says the orthosis is not 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 pay for the wrist hand orthosis (L3916RT). Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found based on the documentation provided that the health plan's denial should be upheld. The enrollee is reported to have chronic, bilateral wrist pain. No detailed history, recent injury or surgery, associated symptoms, review of systems or physical examination, including weakness and/or deformity, has been documented. There is no evidence of diagnostic evaluation (i.e. x-rays) or prescription therapy provision/response (i.e. prescription meds, injections, PT/OT). Therefore, the documentation does not support the medical necessity or reasonableness of the provided 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 the wrist hand orthosis (L3916RT) have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis provided on October 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from July 16, 2019 through July 23, 2019.
You asked the Plan to pay for inpatient mental health care. You say that the stay was 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 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 pay for inpatient mental health care. Our physician reviewer found based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. It did 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 did not have dangerousness to self or others, perceptual disturbance including auditory or visual hallucinations. The health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. We are unable to find an individualized treatment plan however the entire record is not present. It did appear that the records were
supervised and evaluated by a physician. Based upon review the records provided, for the admission of this patient does not meet the criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to himself or others but was without agitation or aggression without perceptual disturbance including auditory or visual hallucinations. 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 mental health care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from July 16, 2019 through July 23, 2019.