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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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 respiratory failure, COPD exacerbation, and cellulitis of the right leg. Your medical problems 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. 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator/portable oxygen concentrator to be provided by the out-of-network provider.

You asked the Plan to pre-approve the oxygen concentrator/portable oxygen concentrator. The Plan denied your request. The Plan says the services are available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator/portable oxygen concentrator to be provided by the out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram provided on July 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for a mammogram. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 a mammogram provided on July 10, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that the chair is needed when you take a shower because you do not want to fall. The Plan denied your request. The Plan says rules for pre-approval have not been met.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 10, 2020, to June 11, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says the admission did not meet established clinical guide lines for inpatient status.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 10, 2020, to June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and diagnostic services provided on October 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says the services were rendered by an out-of-network 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 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 office visit and diagnostic services provided on October 24, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve bilateral blepharoplasty for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says that the submitted photographs do not demonstrate that the upper eyelid margin
approaches to within 2.5 mm of the corneal light reflex.
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 services. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has dermatochalasis with complaints of impaired reading and driving ability especially at
night. There is testing that shows that he has a bilateral visual field loss of 40- 50% with a marginal reflex
distance of 0 mm to both your left and right eye. In this case there is both medical record and examination
evidence that well documents impairment. The impairment is documented to be worse later in the day and
evening (i.e., nighttime driving). The oblique images provide demonstrate the presence of redundant skin on
the eyelashes. The elements of the controlling coverage determination are satisfied. The requested procedure
is recommended.
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 services have been met. Therefore, we decided that the Plan has to preapprove
bilateral blepharoplasty for the enrollee.
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 25, 2020.
You asked the Plan to pay for the office visit. You say that there is a right to recover for services provided to eligible beneficiaries that is not extinguished by plan requirements such as network participation. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 office visit provided by an out-of-network provider on August 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET/CT
You asked the Plan to pre-approve the PET/CT. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says PET is not supported for routine follow-up of the clinical condition presented
The Plan must follow Medicare 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 denying the request to pre-approve the PET/CT. Our reviewer says that no tumor markers were provided, there has been no documentation of symptom progression, and her lesion has been readily detected on conventional CT imaging. Our physician reviewer found surveillance by CT abdomen and pelvis with contrast should be sufficient and clinically appropriate for the member, without the need for PETCT re-imaging, unless her clinical circumstance changes. 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 PET/CT have not been met. Therefore, we decided that the Plan does not have to pre-approve PET/CT
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 you can safely receive the services you need in other settings.
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 surgical repair of a hip fracture
after a fall. Your medical problems 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. 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (CPT 85060) provided to the enrollee on October 19, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied CPT code 85060 may not be paid if furnished to hospital outpatients or non-hospital patients.
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 85060 is "blood smear, peripheral, interpretation by physician." We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found clinical laboratory tests include some services described as anatomic pathology services in CPT (i.e., certain cervical, vaginal, or peripheral blood smears). The CPT code 85060 is used only when a physician interprets an abnormal peripheral blood smear for a hospital inpatient or a hospital outpatient, and the hospital is responsible for the technical component. When an independent laboratory bills a physician interpretation of an abnormal peripheral blood smear, the service is considered a complete or global service, and is not billed under the CPT code 85060. A physician interpretation of an abnormal peripheral blood smear performed by an independent laboratory is considered a routine part of the ordered hematology service (i.e., those tests that include a different white blood count). Therefore, this service would not be covered. We looked at this coder's review, the file, and Medicare rules. 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 pay for laboratory services (CPT 85060) provided to the enrollee on October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another 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 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 is living at home receiving home physical therapy services for increased weakness and falls. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140), the unspecified preventive service (D1999 x 2), the panoramic x-ray (D0330), the consultation (D9310), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223 x 2), and the therapeutic parenteral drug (D9610) provided from November 3, 2020, to November 4, 2020.
You asked the Plan to pay for the dental services. You say that the services rendered were due to an emergency procedure. You say that it was your understanding that they would be covered by your dental benefit. You also say that denying the services would severely put you in a financial hardship. The Plan denied your request. The Plan says that consultation is not listed as a covered service. The Plan says that deep sedation is not listed as a covered service. The Plan says the therapeutic parenteral drug is not listed as a covered service. The Plan says the unspecified preventive service is not listed as a covered service either. The Plan says that 1 limited oral exam is covered per plan year. The Plan says 1 panoramic x-ray is covered every 3 plan years. The Plan also says that the frequency limits for these services have been exceeded.
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 consultation, deep sedation, therapeutic parenteral drug, and unspecified preventive service are not among those covered under this benefit. Additionally, the frequency limits for the limited oral exam and panoramic x-ray have been exceeded. The record shows that the Plan paid for these services that you received on October 30, 2020. The record shows that the provider is not charging you for the limited oral exam, panoramic x-ray, or the unspecified preventive services either. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140), the unspecified preventive service (D1999 x 2), the panoramic x-ray (D0330), the consultation (D9310), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223 x 2), and the therapeutic parenteral drug (D9610) provided from November 3, 2020, to November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) or pay more for the comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on September 24, 2020 by an OON provider.
You asked the Plan to pay for the first intraoral periapical x-ray and pay more for the comprehensive oral evaluation and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The Plan says the first intraoral periapical x-ray is not covered under your contract. The Plan also say that your cost share was applied correctly for the comprehensive oral evaluation and prophylaxis.
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 first intraoral periapical x-ray is not among those covered under this benefit. The contract also clearly states that you are responsible for the difference between the billed amount and allowed amount for the comprehensive oral evaluation and prophylaxis because they were rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) or pay more for the comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on September 24, 2020 by an OON provider.