Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for extremity orthotics provided on March 8, 2021.

You asked the Plan to pay for extremity orthotics. You say that this order was made by telemedicine due to CVID-19 guidelines. The Plan denied your request. The Plan says this provider is not enrolled in the Medicare program and is not payable.

The Plan must follow Medicare rules. Medicare rules say that to receive payment a provider or supplier must be enrolled in Medicare. 

We looked at the file and Medicare rules. This provider is not enrolled in Medicare and is not payable. Based on this information, we decided that Medicare rules for coverage of extremity orthotics have not been met. Therefore, we decided that the Plan does not have to pay for extremity orthotics provided on March 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from July 23, 2021, forward.

You asked the Plan to pre-approve inpatient mental health 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 inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient mental health care. Our physician reviewer found the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of July 27, 2021, forward as this enrollee was not shown to be a danger to herself or others. The enrollee was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care from July 23, 2021, forward.
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 need IRF care. The Plan denied your request. The Plan says your nursing, medical management and rehabilitation needs do not require an interdisciplinary team approach to delivery of rehabilitation care.
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 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. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L3960) provided to the enrollee on September 5, 2020.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation indicates the services are not necessary for treatment of the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We find that code L3960 is not supported and verified in the medical record. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this orthosis has not been met. 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 an orthosis (L3960) provided to the enrollee on September 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 3,
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 codes remain not supported.

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 denied codes are not supported in the medical record. Specifically, the place of service on the
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's
office (POS 11). 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 provided to the
enrollee on March 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy provided by an occupational therapy assistant on August 4, 2020.

You asked the Plan to pay for occupational therapy. You say that the Plan is required to pay non-contracted providers at the preferred provider rate if the service is not available from a preferred provider. You say that many services were not available on an outpatient basis due to the pandemic and the claim should be processed for payment at the in-network benefit. The Plan denied your request. The Plan says the billed code is not appropriate for the service provided.

The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy provided by an occupational therapy assistant on August 4, 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 services are needed so you can get back to your baseline level of function. 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 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 your nursing, medical and rehabilitation needs does 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. Medical conditions 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. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.

Medically necessary services 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. 

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 crowns - porcelain/ceramic (D2740) for teeth #20, 21, 28, and 29, core build-up, including any pins when required (D2950) for teeth #3, 15, 21, 28, and prefabricated post and core in addition to crown (D2954) for teeth # 20 and 29.

You asked the Plan to pre-approve crowns, core build-up and prefabricated post and core. You say that the dental services are medically necessary. The Plan denied your request. The Plan says you have exceeded frequency limits for crowns for 2021, and the remaining 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. The Plan covers crowns twice per calendar year. 

We looked at the file and Medicare rules. The Plan provided documentation showing that coverage was approved for two crowns on July 13, 2021. Based on this information, we determined that the Plan's frequency limit for crowns has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the core buildup and prefabricated post and core are not among those covered services.Therefore, we decided that the Plan does not have to pre-approve crowns - porcelain/ceramic (D2740) for teeth #20, 21, 28, and 29, core build-up, including any pins when required (D2950) for teeth #3, 15, 21, 28, and prefabricated post and core in addition to crown (D2954) for teeth # 20 and 29.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 10, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you gave them your new insurance card and you were unaware they were not a contract provider. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON provider.

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 on February 10, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
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 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 medically necessary. Our physician reviewer found you were admitted to the hospital for surgical repair of a hip fracture after a fall. You are now medically stable with 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. You may benefit from further therapy but do not require an intensive therapy program in an IRF. 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. 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto.

You asked the Plan to pre-approve Xarelto. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto.

Benefits for Xarelto may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits and physical therapy services provided by a chiropractor from February 9, 2021, to February 26, 2021.
You asked the Plan to pay for office visits and physical therapy. You say that your spine required manual adjustment before you could fully heal, and you felt better after this treatment. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.
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. Therefore, we decided that the Plan does not have to pay for office visits and physical therapy services provided by a chiropractor from February 9, 2021, to February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) provided on November 3, 2020.

You asked the Plan to pay for the dental service. You say that had the service been approved originally, as it should have been, you would only have to pay what insurance would have paid. You say that notification was not sent to your provider. You also say that the provider will not adjust the rate. The Plan denied your request. The Plan says there is an annual maximum of $1,000 for covered dental services. The Plan says that the annual maximum benefit has been exhausted. The Plan also says that you are responsible for any remaining amount over the annual maximum benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and the services is listed as covered, the annual maximum benefit has been exhausted.

Additionally, the Evidence of Coverage clearly states that after the annual maximum has been exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) provided on November 3, 2020.
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 this enrollee would benefit from an intensive rehabilitation program to regain some lost function and establish an effective regimen for his medical needs. The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF. The enrollee does not require close supervision by a physician, and the therapy services could be provided at a lower level of care.
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 that 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 does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. 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. Medically necessary services can be provided in a different 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: 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 you are bedridden and do not get the physical
therapy needed. 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 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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
COVID-19 infection, stroke and metabolic encephalopathy. You have been discharged to a skilled nursing
facility. Medical conditions 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. You do require physical and occupational therapy but there is no
documented need for an intensive rehabilitation program. Medically necessary services 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.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that you need the scans done prior to surgery. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to an out-of-network provider.