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

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve the SNF services. You say that the enrollee and her family believe that she
will benefit from a short rehab stay to regain strength and endurance so she may go home to her prior level of
function. The Plan denied your request. The Plan says SNF services are 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 in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says
that daily skilled services are not medically necessary. Our physician reviewer found that based on the
documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee
is ambulating more than 100 feet and tending to activities of daily living with minimal supervision Daily
skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's
condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a
lower level of care (ex. home, assisted living, long term 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 the SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the tubing with an integrated heating element (A4604), the cushion for use on a nasal mask interface (A7032), a nasal interface (A7034), and a positive airway pressure filter (A7038) rendered by the out-of-network (OON) provider on February 26, 2021.
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 had network providers available who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the tubing with an integrated heating element (A4604), the cushion for use on a nasal mask interface (A7032), a nasal interface (A7034), and a positive airway pressure filter (A7038) rendered by the out-of-network (OON) provider on February 26, 2021.The Plan denied your request. The Plan says the items were rendered by an out of network provider, without prior authorization.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 19281) provided to the enrollee on March 9, 2021.
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 per Medicare guidelines, the submission of a device-dependent procedure also requires that a device be submitted on the same claim/day.
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 19281 is "Placement of breast localization device [s] [e.g., clip, metallic, pellet, wire/needle radioactive seeds], percutaneous." 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found that in this case, the record indicates that the enrollee underwent a procedure on March 9, 2021. The operative note indicates that the enrollee underwent a needle localization breast biopsy. The provided record does not indicate
that a device was billed for. The submitted charges are incorrectly billed
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 pay for surgical services (CPT 19281) provided to the enrollee on March 9, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says that rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the requested SNF care is medically necessary and reasonable. Our physician reviewer found that based on the documentation provided, you do qualify for SNF coverage. In this case, you do not have documented skilled nursing needs. However, you do have documented skilled therapy needs. You appear to be functioning below his baseline. There is not clear evidence that you have reached a plateau in function. A trial of skilled therapy is reasonable to establish a maintenance program and/or to prevent deterioration of your condition.

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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can 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. 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 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. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond implant/abutment supported crown (D6092) provided on March 11, 2021.
You asked the Plan to pay for the re-cement or re-bond implant/abutment supported crown. You say that you had a crown reattached to an implant. The Plan denied your request. The Plan says this service is 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 for the re-cement or re-bond implant/abutment supported crown (D6092) provided on March 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on January 15, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11.

Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the wound care services provided from March 1, 2021, to March 15, 2021.
You asked the Plan to waive the copays for the services provided. You say that you were not informed the services would fall under the outpatient hospital benefit. The Plan denied your request. The Plan says the copay applied is applicable and cannot be waived.
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 $200 copay per visit for services performed in an outpatient hospital facility. The file shows that you received services at an outpatient hospital facility. You have been asked to pay a $200 copay per visit for the services provided. The services fall within the outpatient hospital 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 copays for the wound care services provided from March 1, 2021, to March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on February 9, 2021 by an OON provider.
You asked the Plan to pay for the extraction. You say that the provider's office advised you that the treating provider was in-network. The Plan denied your request. The Plan says the service was rendered by a non-participating provider.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the extraction provided on February 9, 2021 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the diagnostic mammography (77065), the diagnostic digital breast tomosynthesis (G0279), and the breast ultrasound (76642) provided on October 30, 2020.

You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to the services provided.

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 $500 annual deductible. This is the amount you must pay out-of-pocket before the Plan will pay their share for your covered medical services.

You have been asked to pay $177.72 for the deductible applied for the diagnostic services provided as you had not previously met the annual deductible required by the Plan contract. This is the Plan's allowed amount for the services provided. 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 deductible for the diagnostic mammography (77065), the diagnostic digital breast tomosynthesis (G0279), and the breast ultrasound (76642) provided on October 30, 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 admission to an IRF is medically necessary and you
were approved by the facility. You do not feel you are receiving the proper care in your current setting. The
Plan denied your request. The Plan says the criteria for an IRF are not met, and the necessary care can be
provided 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 that the complexity of your nursing, medical and rehabilitation needs does not requirean acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require
physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.
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. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenetic testing provided on December 8, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee is an 85-year-old male with long-term drug therapy, chronic pain
syndrome, and sciatica who was taking pain medications and who had molecular pathology/pharmacogenetic
testing. The provided records showed a comprehensive gene testing panel was ordered, however, there was no
specific drug therapy intended to be used that was being screened and no justification made for testing, such a
comprehensive test when only a few would be needed to lead to improved outcomes. Therefore, this request for
molecular pathology/pharmacogenetic testing will be considered not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have
to pay for the pharmacogenetic testing provided on December 8, 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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 you were admitted for lumbar osteomyelitis, congestive heart failure and a urinary tract infection. 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. Although 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. In conclusion, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pay for IRF care. You say that you need inpatient rehabilitation services. The Plan denied your request. The Plan says your records show that your care is not complex and does not require a team of providers. You can safely receive the necessary care 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 pay for 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require
physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. 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. 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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation provided on April 13, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you were led to believe you had $2,000 for dental per year and the claim should be reconsidered. The Plan denied your request. The Plan says the service is not a covered 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, 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 cone beam CT capture and interpretation provided on April 13, 2021.