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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 that in this case, the enrollee was admitted to an acute care hospital due to hypoxic respiratory failure from pulmonary edema and gastrointestinal bleeding. The enrollee continues to receive acute care services that have not been denied. The medical records provided do not indicate that the enrollee requires acute care services that he is not currently receiving that would be available at the LTACH. The elements of the coverage rules are not satisfied. 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: 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 requires maximum assistance. The Plan denied your request. The Plan says the enrollee does not need an intensive program with a team of health care professionals.
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 was admitted to the acute care hospital for poor appetite and bacteremia. His medical conditions are stable. There are no complex nursing needs. He does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation 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: 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 these services are medically necessary. The Plan denied your request. The Plan says that your care needs can be met at home with home health care, or in a skilled nursing facility setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pneumonia. Your medical conditions are stable. There are 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 do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (99212 and 90836) provided on July 14, 2020, through September 8, 2020.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because you have always been reimbursed for these services. The Plan denied your request. The Plan says you must receive your care from a provider who is eligible to participate in Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (99212 and 90836) provided on July 14, 2020, through September 8, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on January 24, 2020.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was not submitted with an appropriate diagnosis code.
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 claim for the emergency department visit was not filed until January 27, 2021. 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 emergency department visit provided on January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 11, 2021.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen (15) hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to hold you harmless for the pump and pad for water circulation (E0236 and E0249) and pneumatic compression device (E0650 and E0673) provided on September 9, 2020, through December 7, 2020.
You asked the Plan to hold you harmless for the pump and pad for water circulation and pneumatic compression device.. You say that you would like reconsideration because you believe the provider is double billing for the same supplies. The Plan denied your request. The Plan says that you do not meet Medicare coverage criteria for the billed supplies.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the pump and pad for water circulation and pneumatic compression device. by a contract provider. The file does not show that the Plan provided notice that the pump and pad for water circulation and pneumatic compression device. would not be covered. Under Medicare rules, this means the pump and pad for water circulation and pneumatic compression device. is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the pump and pad for water circulation (E0236 and E0249) and pneumatic compression device (E0650 and E0673) provided on September 9, 2020, through December 7, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance (E0673) provided on November 12, 2020.
You asked the Plan to pay for the segmental gradient pressure pneumatic appliance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this device is not covered because the member received it while in a facility.
The Plan must follow Medicare rules. Medicare rules say that if the base PCD is not covered, related accessories are not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the segmental gradient pressure pneumatic appliance have not been met. Specifically, there is no evidence that the base PCD has been covered, so the billed accessory is not eligible for reimbursement. Therefore, we decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance (E0673) provided on November 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) (CPT Code 29877) and arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty) (CPT Code 29881), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that you think that with the arthroscopy and other adjuvant treatments, the enrollee may be able to avoid knee replacement for a considerable amount of time. The Plan denied your request. The Plan says the degree of arthritis on the enrollee's x-ray is too advanced to support the requested service, and as such, the appeal remains denied at this time.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. The cortisone injection was noted to be 27 weeks prior to the March 30, 2021, exam, and physical therapy was noted from 2019. A clear history of mechanical locking associated with intraarticular loose bodies or meniscal tears is not evident. Furthermore, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective treatment for the noted comprehensive knee pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for arthroscopy, knee, surgical: debridement/shaving of articular cartilage (chondroplasty CPT code 29877); and arthroscopy, knee surgical: with meniscectomy (medial OR lateral, including meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty CPT code 29881) is not medically reasonable or 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) (CPT Code 29877) and arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty) (CPT Code 29881), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in the setting of lumbar spondylosis and chronic low back pain has not been demonstrated in the peer-reviewed literature.
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 requested services are not considered medically reasonable and necessary in this case. You are being treated for spondylosis without myelopathy or radiculopathy, lumbar region and chronic back pain. Detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. You are noted to have had five sessions of physical therapy (and then stopped secondary to having 3 stents placed.) There is no indication of completion of a full course of therapy, with failure. Furthermore, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology.
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the dental services (D0150 D1110
D0210) received January 20, 2021, from the out-of-network provider.
You asked the Plan to pay an additional amount for the dental services (D0150 D1110 D0210). You say that
you should be able to see any dental provider because your Plan is a Preferred Provider Organization (PPO).
The Plan denied your request. The Plan says if you choose to see an out-of-network dentist you might be billed
for charges above what the Plan pays, even for services listed with a $0 copayment.
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 payment is in excess of
that which is covered under this benefit. If you choose to see an out-of-network dentist, you might be billed for
charges above what the plan pays, even for services listed as $0 copayment. The Plan agreed to pay 100% of
the allowed amount for the dental services. You are responsible for any amount above the allowed amount that
may have been billed by the out-of-network provider. Therefore, we decided that the Plan does not have to pay
an additional amount for the dental services (D0150 D1110 D0210) received January 20, 2021, from the outof-
network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) rental provided on September 4, 2020.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the records do not support the item billed in this case.
The Plan must follow Medicare rules. The rules say that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the item provided in this case. Specifically, the record did not include an itemized shipping invoice and proof of delivery for the billed item in this case.
The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) rental provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia block provided on May 8, 2020, by an OON
provider.
You asked the Plan to pay for the anesthesia block. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the 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 anesthesia block provided on May 8, 2020, by
an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit and ankle x-ray provided on
October 9, 2020, and October 30, 2020.
You asked the Plan to waive the deductible for the office visits and ankle x-ray. You say that this is your sole
insurance, and the claims should be paid. The Plan denied your request. The Plan says the deductible applied
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that your deductible is $750. This is the amount you have to pay out-of-pocket
before we will pay our share for your covered medical services. Until you have paid the deductible amount,
you must pay the full cost for most of your covered services.
The item or service you asked the Plan to waive the deductible for fall within the "Physician/Practitioner
services, including doctor's office visits" and "Outpatient diagnostic tests and therapeutic services and supplies"
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750
deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been
met at the time the office visits and ankle x-ray were received on October 9, 2020, to October 30, 2020.
Therefore, we decided that the Plan does not have to waive the deductible for the office visit and ankle x-ray
provided on October 9, 2020, and October 30, 2020.