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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the member is unsafe to discharge home. The Plan
denied your request. The Plan says that the enrollee can safely receive the services needed 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 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. 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 frequent falls and
possible subacute stroke. The enrollee's 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. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroscopic rotator cuff repair for the enrollee.
You asked the Plan to pre-approve the repair. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is considered experimental, investigational, and unproven.
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 repair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is documented failure of conservative measures. However, there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of superior capsular release as an effective treatment. There was no evidence of any extenuating circumstances in this patient's specific case either. Therefore, the request for superior capsular reconstruction would not be medically reasonable or 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 the repair have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroscopic rotator cuff repair for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNFcare for the enrollee.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 identifiable skilled nursing service needs. There are no 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 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-approveSNF care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99203)to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you have seen this provider for many years and want to continue using this provider.The Plan denied your request. The Plan says the services are not emergent. There are network providers available that can provide these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 an office visit (99203) to be provided by an out of network (OON) provider
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for emergency room services billed under claim number AJXZWZ4Z3Y.

You asked the Plan to pay for the emergency room services bill under claim number AJXZWZ4Z3Y. You say that the records provided support the services in dispute.The Plan denied your request. The Plan says that the emergency room services were already paid for under claim number AJX8AS4UH7.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the plan has not substantiated their argument that the claim in dispute is a duplicate of a claim already paid. The records provided show that the enrollee was evaluated by more than one provider while in the emergency room. The records also show that the two claims the Plan is saying are duplicates have been billed by different providers with different NPI numbers.The Plan has not submitted sufficient documentation to demonstrate that the claim in dispute is in fact an exact duplication of another claim previously pain. Therefore, we decided that the Plan has to pay for emergency room services billed under claim number AJXZWZ4Z3Y.

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-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the submitted records show that you had spine surgery on February 8, 2021. You were deemed medically stable for discharge per rehab and need assistance with rolling, transfers, and dressing. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require intensive physician or nursing supervision in an IRF. While you may benefit from further therapy, you do not require an intensive therapy program in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and service
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea right lumbar radiofrequency ablation (64635, 64636).You asked the Plan to pre-approvethis service. You say that this service is medically necessary as the enrolleehas received greater than 50% relief from previous radiofrequency lesioning for four months.The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of this service.The Plan follows Medicare rules. Medicare rules say that repeat denervation procedures involving the same joint will only be considered medically necessary if the patient experienced 50% improvement of pain and improvement in patient specific activities of daily living (ADLs)that are documented for at least 6 months.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 this service. Our reviewer says that this service is not medically necessary. Our physician reviewer found that criteria for a right lumbar radiofrequency ablation (RFA) are not met. Proper documentation of required pain relief intensity and duration from the previous RFA procedurehave not been provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pre-approvea right lumbar radiofrequency ablation (64635, 64636)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the rituximab injection rendered on September 14, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code J9312 is not payable.
The Plan must follow Medicare rules. The rules say that non-pass through drugs and biologicals (status indicator K) are not typically packaged under the OPPS. We looked at the file and Medicare rules. The provider billed drug code J9312 under the OPPS. This code has a status indicator of K and is not payable under the OPPS. Therefore, we decided that the Plan does not have to pay for the rituximab injection rendered on September 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approveneuropsychological testing, first hour (CPT Code 96132).You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says the services are not 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 physician reviewer found neuropsychological testing is intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain including detection of neurologic disease based on quantitative assessment of neurocognitive abilities, differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of central nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous system disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders, this enrolleedoes not meet the medical necessity criteria for neuropsychological testing as this enrolleehas had a decline in cognitive function since 2015 and the use of neuropsychological testing would not impact the enrollee's treatment.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 not been met.Therefore, we decided that the Plan does not have to pre-approveneuropsychological testing, first hour (CPT Code 96132).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on October 23, 2020.You asked the Plan to waive the copayment for ambulance service. You say that you do not agree with this copayment. 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 $325 copayment for ambulance services. You have been asked to pay a $325 copayment for ambulance service. Ambulance service falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that the stockings are medically necessary. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medicallynecessary, 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 topre-approve the LTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with COVID-19 pneumonia and associated respiratory failure. She required trach and PEG tube placement. She does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. The LTACH services are not reasonable or 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870). You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary. 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the spacer device is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional logisticare mileage.You asked the Plan to pre-approveadditional mileage. You say that the service is medicallynecessary.The Plan denied your request. The Plan says the service requested exceeds the 50 miles per one way trip benefit maximum.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 one-way trips not exceeding 50 miles trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Specifically, you are allowed a benefit maximum of 50 miles per each one way trip. Any mileage over 50 miles is not a covered benefit.Therefore, we decided that the Plan does not have to pre-approveadditional logisticare mileage
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical procedures (D9215) provided on October 1, 2020.
You asked the Plan to pay for the local anesthesia. You say that you feel that this service should be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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. Therefore, we decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical procedures (D9215) provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on May 5, 2020.
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare
program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the dental services provided on May 5,
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional logisticare mileage.You asked the Plan to pre-approveadditional mileage. You say that the service is medically necessary.The Plan denied your request. The Plan says he service requested exceeds the fifty (50) miles per one way trip benefit maximum.Medicare does not cover transport in avehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of twenty-four (24) one-way trips not exceeding fifty (50) miles trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Specifically, you are allowed a benefit maximum of fifty (50) miles per each one way trip. Any mileage over fifty (50) miles is not a covered benefit.Therefore, we decided that the Plan does not have to pre-approveadditional logisticare mileage
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray and extraction provided on May 28, 2020, and June 17, 2020.You asked the Plan to pay forthe first intraoral periapical x-ray and extraction. You say that the enrollee was hospitalized due to the severity of the infection, and put on antibiotics. You also say that the enrollee had the tooth pulled because it still bothered them.The Plan denied your request. The Plan says these services 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.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray and extraction provided on May 28, 2020, and June 17, 2020