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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). You do not require daily skilled nursing and/or skilled therapy services. You could benefit from continued intermittent services at a lower level of care. Although you made slow progress with therapy, her functional improvement has plateaued, there is no indication that transfer to a skilled nursing facility is required. You can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 has a better chance to return to his previous level of function at an IRF level of care. The Plan denied your request. The Plan says the enrollee does not need an intensive therapy program with multiple visits from a rehab doctor per week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital for weakness and a fall associated with progression of multiple sclerosis. His medical conditions are stable. There are no complex nursing needs. He does not require treatment by multiple therapies in an intensive rehabilitation therapy program. He does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the revision of total shoulder arthroplasty services coded
23474 and the removal of prosthesis coded 23334 provided on December 17, 2020.
You asked the Plan to pay for the revision of total shoulder arthroplasty services and the removal of prosthesis.
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the
services billed are not supported by the documentation.
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 CPT codes 23474 and 23334 are not supported in the medical record. Specifically, the operative
report did not include documentation of revision of total shoulder arthroplasty of the humeral and glenoid
component, including allograft when performed; therefore, code 23474 cannot be verified. The operative report
did not include documentation of a removal of a humeral or glenoid component prosthesis, including
debridement and synovectomy when performed; therefore, code 23334 cannot be verified. Based on this
information, we decided that Medicare rules for coverage of the revision of total shoulder arthroplasty services
and the removal of prosthesis have not been met. Therefore, we decided that the Plan does not have to pay for
the revision of total shoulder arthroplasty services coded 23474 and the removal of prosthesis coded 23334
provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (98943, 99202, 97140) provided to you on January 5, 2021.
You asked the Plan to pay for the chiropractic services. You say that these services should be covered. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (98943, 99202, 97140) provided to you on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on June 30, 2020.
You asked the Plan to pay for the laboratory test. You say that you are appealing the claim with medical records for further processing. The Plan denied your request. The Plan says prior authorization was required but 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on June 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 1, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you were shocked by the high charges and were not prepared to pay a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for ultrasounds. You have been asked to pay a $100 copayment for an ultrasound. An 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 provided on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an annual wellness visit provided on February 17, 2021.
You asked the Plan to waive the coinsurance for an annual wellness visit. You say that you should not owe a copayment for annual wellness exams. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% coinsurance for out-of-network annual wellness visits. You had an annual wellness visit on February 17, 2021, from an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $129.95 and 40% of that is $51.98.
You have been asked to pay the total coinsurance amount of $51.98 for an annual wellness visit. An annual wellness visit falls within the annual wellness visits 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 coinsurance for an annual wellness visit provided on February 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve conduction study (95912) and needle electromyography (95886) provided on September 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nerve conduction tests. You say that you feel that this should be covered because care was available with this provider faster than what was available with in-network provider. Also, the results were used by your in-network provider to determine surgery. 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 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 nerve conduction study (95912) and needle electromyography (95886) provided on September 30, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the member's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 daily skilled services are not necessary. Our physician reviewer found that the member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of chronic medical problems. His physical function is at or near his baseline and he can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 cannot function at home. The Plan denied your request. The Plan says you can be treated in a less intensive 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. Our physician reviewer found the records show that you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve pain management services to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 pain management services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kadcyla.

You asked the Plan to pre-approve Kadcyla. You say that this request is medically necessary. The Plan denied your request. The Plan says the coverage criteria for the requested drug have not been met.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Kadcyla. Our reviewer says that the requested drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found in this case, the enrollee has been diagnosed with metastatic urothelial malignancy. The requested drug is not FDA-approved for the enrollee's condition. In addition, there is no compendia support for the enrollee's specific 2 neu + transitional cell carcinoma.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Kadcyla have not been met. Therefore, we decided that the Plan does not have to pre-approve Kadcyla.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents via a controlled
release vehicle into diseased crevicular tissue, per tooth (D4381), reattachment of tooth fragment, incisal edge
or cusp (D2921), and drugs or medicaments dispensed in the office for home use (D9630) provided February 3,
2021.
You asked the Plan to pay for the delivery of antimicrobial agents, reattachment of tooth fragment and drugs
dispensed for home use. You say that you would like the Plan to pay its share of the bill. The Plan denied your
request. The Plan says these services are not covered under your dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per
tooth (D4381), reattachment of tooth fragment, incisal edge or cusp (D2921), and drugs or medicaments
dispensed in the office for home use (D9630) provided February 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammography (77065) and ultrasound of the breast (76641) provided February 5, 2021.

You asked the Plan to waive the copayment for the diagnostic mammography and ultrasound of the breast. You say that this copayment is too much. The Plan denied your request. The Plan says the claim has processed correctly in this case.

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 $50 copayment for diagnostic procedures and radiology services.

You have been asked to pay a $50 copayment for the diagnostic mammography and a $50 copayment for the ultrasound of the breast. These services fall within the diagnostic procedures and radiology services benefit categories. 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 diagnostic mammography (77065) and ultrasound of the breast (76641) provided February 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 9, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.

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 requested CPT codes are not supported in the medical record. Specifically, the records provided do not show that lab services were performed with blood sampling. The records show that a urine specimen was collected. The billed services cannot be verified. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341).

You asked the Plan to pre-approve periodontal scaling and root planing. You say that the service is medically necessary because periodontal disease is causing issue with your gums and bone loss. The Plan denied your request. The Plan says the documentation submitted does not demonstrate evidence of significant bone loss and/or radiographic root surface calculus on 4 or more teeth per quadrant as is required to qualify for the procedure under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers periodontal scaling and root planing when the services are medically necessary and reasonable. 

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 periodontal scaling and root planing. Our reviewer says that the supplied x-rays are of poor quality and cannot be used to determine if there is root surface calculus or radiographic evidence of noticeable loss bone support. From the provided records it cannot be determined that the requested services are medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) cervical spine (72141).
You asked the Plan to pre-approve the MRI. You say that the medical records provided will show proof of medical necessity of the requested service. The Plan denied your request. The Plan says the records do not show that other treatments have been tried and did not help therefore, the criteria has not been met.
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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee has diabetic neuropathy. The record also indicates that the enrollee has left (greater than right) shoulder pain with left hand weakness. No neurological examination is documented. No plain films are performed. The record does not document duration, evidence of trauma or other treatment. Nerve conduction studies are consistent with bilateral polyneuropathy. The records provided do not support the medical reasonableness and necessity, as defined by Medicare rules, of the requested 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) cervical spine (72141).