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 you need detailed treatment. The Plan denied your request. The Plan says your needs can be met at a lower level of care.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require physical and occupational therapy, 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. 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 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 the review has determined that there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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 inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require physical and occupational therapy, 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. 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 pay for the office visit rendered on September 9, 2020.
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 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 states that the services are not covered; however, there is no
documentation or further explanation as to why the services are not covered by Medicare. The Plan has not
provided any Medicare rules to support that the services cannot be covered. Therefore, we decided that the Plan
has to pay for the office visit rendered on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on August 17, 2020.
You asked the Plan to pay for the office visit. You say that the most appropriate way to help the patient was to provide evaluation and management. You say that the service was medically necessary, and the claim should be considered for payment. The Plan denied your request. The Plan says prior authorization was not obtained prior to rendering services.
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 office visit provided by an out-of-network provider on August 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging.
You asked the Plan to pre-approve myocardial perfusion imaging. You say that this service is medically
necessary. The Plan denied your request. The Plan says the coverage criteria have not been met in this case.
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion imaging is subject to the criteria
listed 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 myocardial perfusion imaging. Our
reviewer says that the requested service is not medically necessary and reasonable. Our physician reviewer
found that in this case, the enrollee has a history of diabetes and hypertension. The enrollee is asymptomatic
and has a normal physical examination. The provided record does not document any anginal equivalents. An
EKG was noted to be abnormal. No other work-up has been performed. The enrollee does not have an
indication for the requested study enumerated in the local coverage determination. The elements of the general
criteria are not satisfied. The elements of the coverage determination are not satisfied. The requested service
cannot be recommended 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 myocardial perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the initial consultation to be performed by an out-of-network provider.
You asked the Plan to pre-approve the service. You say that you have a detached retina and are bleeding in the back of your eye. The Plan denied your request. The Plan says there are available providers in the network of the plan that may render the service requested.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the initial consultation to be performed by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the aquatic exercise services received on January 14, 2021.
You asked the Plan to pay for the aquatic exercise services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says an itemized bill is required to be submitted for these services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the aquatic exercise services are not supported in the medical record. Specifically, an itemized bill was not submitted for review. While there is a prescription order in the file for these services, there is no itemized bill for the services received. Based on this information, we decided that Medicare rules for coverage of the aquatic exercise services have not been met. Therefore, we decided that the Plan does not have to pay for the aquatic exercise services received on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on January 27, 2021, by an
OON provider.
You asked the Plan to pay for the rest home visit. You say that the nursing home was responsible for obtaining
authorization. The Plan denied your request. The Plan says no prior authorization was 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 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 rest home visit provided on January 27, 2021,
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (77523, 77522, 77525, 77520).
You asked the Plan to pre-approve proton beam radiation therapy. You say that this is medically necessary. The Plan denied your request. The Plan says proton radiation therapy is not proven superior to intensity-modulated radiation therapy (IMRT).
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 proton beam radiation therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. The patient agreed to consent to a registry study; however, registry studies are not clinical trials or studies, and have a much less rigorous development process.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy (77523, 77522, 77525, 77520).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered on October 11, 2020.
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 the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that inpatient claims are billed with POS code 21.
We looked at the file and Medicare rules. The file shows that the claim was billed with Place of Service (POS)
code 21 for inpatient hospital; however, the enrollee was not under inpatient status for the date of service at
issue. 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 physician services rendered on October
11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions, five retainer crowns, and two preventive procedures provided on July 27, 2020, and July 31, 2020.
You asked the Plan to pay for the extractions, retainer crowns, and preventive procedures. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the two extractions, five retainer crowns, and two preventive procedures provided on July 27, 2020, and July 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0428, A0425) provided January 3, 2021. You asked the Plan to waive the copayment for the ambulance services. You say that you did not agree to the transport and the provider told you not to worry about the copay. The Plan denied your request. The Plan says you signed a financial acknowledgement form for the transport and the copayment was applied correctly. 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 $150 copayment for each Medicare-covered one-way ground ambulance transport. You have been asked to pay a $150 copayment for the ambulance services. This service falls within the ambulance services 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 the ambulance services (A0428, A0425) provided January 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services you received from an out-of-network provider from November 19, 2020, to December 24, 2020.You asked the Plan to pay forthe 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 carefrom 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 forthe services you received from an out-of-network provider from November 19, 2020, to December 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 21, 2021, by a
non-participating provider.
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 the services were rendered by a non-participating provider without prior authorization.
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 referring provider 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 laboratory services provided on January 21, 2021, by a non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder magnetic resonance imaging.
You asked the Plan to pre-approve Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) (73221). You say that an MRI is appropriate. The Plan denied your request. The Plan says there has been no x-rays or failed treatment.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) (73221). Our reviewer says that an MRI is not medically reasonable or necessary. Our physician reviewer found based on the provided documentation, there was no evidence of the patient having fully exhausted conservative care including non-steroidal anti-inflammatory drugs (NSAIDS) and physical therapy/exercises, and there was no provided x-ray results to help justify MRI at this time. There were no signs suggestive of a red flag diagnosis present. Only decreased range of motion was detected on exam. Therefore, this request for MRI shoulder will be considered not 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 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) (73221) have not been met. Therefore, we decided that the Plan does not have to pre-approve shoulder magnetic resonance imaging.
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 this is medically necessary. The Plan denied your request. The Plan says the services could be safely received in other settings, for example: a skilled nursing facility, home with home health and home physical 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 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 enrollee was admitted for non surgical management of a hip fracture after a fall and have been discharged home. There is ongoing weakness and difficulty with ambulation. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided on February 3, 2021 by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that the Plan should have paid for these services in full. The Plan denied your request. The Plan says the charges exceed the allowable amounts.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided on February 3, 2021 by an OON provider.