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

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinuation of SNF care from December 25, 2020, forward.You asked the Plan to pre-approveSNF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met.Therefore,we decided that the Plan does not have to pre-approvecontinuation of SNF care from December 25, 2020, forward
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the flu shot provided on November 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the flu shot. You say that you are on a fixed income and someone else should pay for this service. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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 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 flu shot provided on November 27, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forrepair of complex retinal detachment (67113) Hyaluronidase recombinant injection (J3473) non-covered item/service (A9270) and triamcinolone acetonide injection (J3300) provided January 10, 2020.You asked the Plan to waive the copayment forthe surgical procedure. You say that your right eye was operated on in a 2 step process. You feel that you should only be responsible for one copay because you view this as one treatment to re-attach the retina in my right eye.The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.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 $300 copayment per surgical visit. Youhave been asked to pay $300 copayment per surgical visit for the surgical procedure. The surgical procedure falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 forrepair of complex retinal detachment (67113) Hyaluronidase recombinant injection (J3473) non-covered item/service (A9270) and triamcinolone acetonide injection (J3300) provided January 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for anemia, vomiting and weakness. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for falls and problems with balance. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on August 7, 2020.
You asked the Plan to waive the copayment for a colonoscopy. You say that you were not charged for the same procedure in the past and feel that the colonoscopy should be considered preventative. 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 also clearly says that there are no cost-sharing charges for colorectal cancer screenings. If you have a prior history of colon cancer, or have polyps removed during a previous colonoscopy, ongoing colonoscopies are considered diagnostic and are subject to cost-sharing charges. Your contract with the Plan also clearly says that you must pay a $100 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The record shows that you had polyps removed during a previous colonoscopy. Therefore, the colonoscopy you received on August 7, 2020, is considered diagnostic, not preventative, and you are responsible to pay the $100 copayment. You have been asked to pay a $100 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 a colonoscopy provided on August 7, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the head and PET/CT head to thigh 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 clinical information needed to determine medical necessity has not been
supplied.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary. 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 services. Our reviewer says that the
requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has a
biopsy-proven aggressive right mesothelioma of the right pleural space. MRI of the brain is indicated for
staging. To note - metastatic disease to the brain may be present without focal neurological symptoms. PET/CT
is reasonable to determine the extent of right pleural disease as the presence of an effusion can make the
determination impossible to determine on CT alone. Also, PET/CT would allow for evaluation of distant
metastases as well.
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
MRI of the head and PET/CT head to thigh for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 73562 provided.

You asked the Plan to pay for the x-ray services. 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 payable.

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 73562 is radiologic examination, knee; 3 views.

We find that CPT code 73562 is not supported in the medical record. Specifically, the documentation supports that one unit of each (Code 73562-RT and 73562-LT) were provided, which were previously processed and paid. There is no additional documentation supporting additional studies which were billed. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met.Therefore, we decided that the Plan does not have to pay for the x-ray services coded 73562 provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment extraspinal
provided on August 3, 2020.
You asked the Plan to pre-approve chiropractic manipulative treatment extraspinal (98943). You say that the
Plan has paid for this procedure before. The Plan denied your request. The Plan says they paid for the
procedure once before as a courtesy but this procedure is 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 service at issue is not manual manipulation of the spine. This procedure is a
statutorily excluded service. Therefore, we decided that the Plan does not have to pre-approve chiropractic
manipulative treatment extraspinal provided on August 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 based on the documentation provided, that the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth #3.
You asked the Plan to pre-approve the core build up. You say that the core build up is necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan also says that any services not listed are 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. The Customer Handbook clearly states that if a dental item or service is not listed in the benefit chart, then it is not covered. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth #3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital or ambulatory surgical center call (D9420).
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your handbook as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve hospital or ambulatory surgical center call (D9420).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 2, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for the lab services. You say that You did not provide an argument in your appeal
request. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered
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 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 lab services provided on June 2, 2020 by an out of network
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Myopro Motion G orthotic device for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary, as standard rehab techniques and bracing have failed to improve symptoms.The Plandenied your request. The Plansaysthis device has deluxe features that exceed medical need.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that the Myopro Motion G orthotic device at issue in this case is medically reasonable and necessary. Current guidelines consider robotic therapy of "uncertain utility compared with dose-matched conventional upper limb exercise therapies".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 device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Myopro Motion G orthotic device for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on May 22, 2020.You asked the Plan to waive the copayment for an emergency room visit. You say that you don't think you should have been charged because you shouldn't have been discharged originally. The Plan denied your request. The Plan says the correct copayment 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). Your contract with the Plan clearly says that you must pay a $120 copayment for emergency care. You have been asked to pay a $120 copayment for an emergency room visit. An emergency room visit falls within the emergency care 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 emergency room visit provided by a participating provider on May 22, 2020.