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 for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not 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 there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and 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 she 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea positron emission tomography (PET) and computed tomography (CT) scan.You asked the Plan to pre-approvethe PET/CT scan. You say that the enrollee's PET scan revealed an adrenal mass and the office did a biopsy. You say that it did not come back as metastatic but did come back as adrenal malignancy. You say that a PET/CT scan is needed in order to check if the mass has gotten bigger and then to order a re-biopsy or to note its being benign.The Plan denied your request. The Plan says the guidelines for coverage of PET/CT fusion scans is limited. The Plan says that the clinical information provided shows that the requested study would exceed the allowed limit.The Plan must followMedicare rules. Medicare rules say that PET scans 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 denyingthe request to pre-approve the PET/CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has stage III non-small cell lung cancer who is on Imfinzi. The enrollee has a suspicious nodule adrenal gland, but a biopsy was negative. Our physician reviewer found that the enrollee has had more than 3 PET/CT scans and says that the adrenal nodule can be followed up on with a re-biopsy or an MRI/CT.We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that Medicare rules for coverage of the PET/CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea positron emission tomography (PET) and computed tomography (CT) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 15, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider 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 physician services provided to the enrollee on September 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF whenthe 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with compression fracture and ulcerative colitis. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for pain. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy. The enrollee was at a stand by assist level for functional mobility including gait to 40 feet with a rolling walker. The enrollee required varying assist with activities of daily living.  

There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on July 8, 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 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 forthe medical services provided to the enrollee by an out-of-network provider on July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty semi-electric hospital bed.
You asked the Plan to pre-approve these services. You say that you have back and hip pain. The Plan denied your request. The Plan says you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a heavy duty semi-electric hospital bed is covered for enrollees who weigh 350 to 600 pounds. We looked at the file and Medicare rules. The records show that you weight 237 pounds. 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 a heavy duty semi-electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefour core buildups, including any pins when required (D2950 x4).You asked the Plan to pre-approvethe core buildups. The Plan denied your request. The Plan says this service is not covered.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.Therefore, we decided that the Plan does not have to pre-approvefour core buildups, including any pins when required (D2950 x4)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approved crown (D2791) for tooth # 5.

You asked the Plan to pre-approve the dental service. You say that the implants and crown should be covered.The Plan denied your request. The Plan says 1 crown is covered per tooth every 5 years. The Plan says that the frequency limit for this service has been reached.

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 frequency limit of 1 crown per tooth every 5 years has been reached. The record shows that the Plan paid for a crown for tooth # 5 that you received.Therefore, we decided that the Plan does not have to pre-approved crown (D2791) for tooth # 5.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetransvenous phrenic nerve stimulation for the enrollee.You asked the Plan to pre-approvethe services. You say that this is not medically necessary.The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that transvenous phrenic nerve stimulation is not a covered benefit.The requested procedure is statutorily not covered for central sleep apnea. 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-approvetransvenous phrenic nerve stimulation for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the service is available in-network. The Plan does not cover out-of-network services except when it is an emergency care or urgently needed services; or if Medicare requires the plan to cover and providers in the network cannot provide needed care (prior authorization is needed).
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 these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea dental extraction to be performed by a periodontist.You asked the Plan to pre-approvea dental extraction to be performed by a periodontist. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says dental services must be performed by a participatinggeneral dentist in order to be covered by the Plan's supplemental dental benefit.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 unless provided by a participating general dentist.Therefore, we decided that the Plan does not have to pre-approvea dental extraction to be performed by a periodontist.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an ambulance trip provided by a non-participating provider on December 24, 2019.You asked the Plan to waive the coinsurance for an ambulance trip. You say that you disagree with the responsibility of the claim. The Plan denied your request. The Plan says the correct coinsurance has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 5% coinsurance for ambulance services. The enrollee has been asked to pay a 5% coinsurance of the allowed amount for an ambulance trip. The allowed amount is $463.26. The total amount you are being asked to pay is $23.16 ($463.26 x 5% = $23.16). An ambulance trip falls withinthe ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an ambulance trip provided by a non-participating provider on December 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea blood pressure monitor.You asked the Planto pre-approvethe monitor. You say that this is needed to independently monitor fluctuating blood pressure levels.The Plandenied your request. The Plansaysthis is not a covered benefit, as it is available over the counter.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plandoes not haveto pre-approvea blood pressure monito
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services.You asked the Plan to pay forhome health services. You say that you need home health services for your condition.The Plan denied your request. The Plan says you are not homebound and therefore do not qualify for home health services.The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, the record indicates that you are not homebound.Therefore, we decided that the Plan does not have to pay forthe home health services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology servicesprovided on February 19, 2020.You asked the Plan to pay for the diagnostic radiology services.The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 Plandid not pre-approve the diagnostic radiology services.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 diagnostic radiology services provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist visit and Part B drug provided on July 21, 2020.
You asked the Plan to waive the cost share for the specialist visit and Part B drug. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a specialist visit and a Part B drug on the date of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.
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 $40 copayment for each specialist visit and a 20% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist and a Part B drug on July 21, 2020. You have been asked to pay a 20% coinsurance for the Part B drug, totaling $123.53. The Part B drug falls within the Medicare Part B prescription drugs benefit category. You have also been asked to pay a $40 copayment for the specialist services. The specialist services fall within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amounts 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 cost share for the specialist visit and Part B drug provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on June 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the orthosis. You say that claim denied for financial liability waiver not signed or mission. Please review for payment.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 exceptionthat would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on June 17, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health services for the enrollee.You asked the Plan to pre-approvehome health services. You say that home health care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.We asked our physician reviewer tocarefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the documentation doesn't support that the enrollee requires additional skilled rehab services to provide treatment that is medically necessary. The enrollee does not require additional rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The enrolleehas been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.  The approved 4 physical therapy sessions should be adequate to establish 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 home health services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health services for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, first hour (99291) provided August 17, 2019 to August 21, 2019.

You asked the Plan to pay for the critical care. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records do not support the billed 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, the documentation submitted did not support a critical care visit of 30-74 minutes was performed. The documentation does not include the time spent providing this service. The plan had made multiple attempts were made to contact the provider for the additional information. Based on this information, we decided that Medicare rules for coverage of the critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) provided August 17, 2019 to August 21, 2019.