Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided from August 7, 2020, through August10, 2020.You asked the Plan to waive the copayment forinpatient hospital care. You say that you should not have to pay the copayment. The Plan denied your request. The Plan says the copayment was applied correctly.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 $350 copayment per day, days 1-4, for inpatient hospital care. Youhave been asked to pay a $350 copayment per day, days 1-4, for inpatient hospital care. The services at issue fall within the inpatient hospital 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 forinpatient hospital care provided from August 7, 2020, through August 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee does not require daily skilled therapy services on an inpatient basis.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 services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and was treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at an independent to supervision level with functional mobility. He required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. He 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approveeight (8) home health PT visits (CPT Code G0151).You asked the Plan to pre-approvethe PT home visits. You say that you just had a total hip replacement and need therapy to learn how to walk properly.The Plan denied your request. The Plan says the services are not necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 PT home visits. Our physician reviewer found the eight (8) home health physical therapy visits (CPT Code G0151) are not medically necessary. The documentation does not reveal that skilled therapy services are required to effectively provide treatment, care, and/or services inorder to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. The documentation does not reveal you are homebound, or that your functional level needs ongoing skilled PT. You are independent in a home exercise program. Skilled therapy is 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 PT home visits have not been met.Therefore, we decided that the Plan does not have to pre-approveeight (8) home health PT visits (CPT Code G0151).
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 requestedIRF 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 a fall and dehydration. The patient is living at home with home health services but has continued 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-approveacute 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 fora knee fracture after a fall. 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-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, 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 to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient appears to be unstable at the time, requiring additional short-term acute care services which can be safely administered at the current facility. The patient 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 patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered when the patient is more stable and treatment has completed.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-approveLTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveexcess skin removal.You asked the Plan to pre-approvethe requested services. You say that the excess skin is causing pain in your neck and shoulders.The Plan denied your request. The Plan says cosmetic surgery is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that cosmeticsurgery or expenses incurred in connection with such surgery 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 requested services. Our physician reviewer found that you have documentation consistent with a possible functional impairment related to excess soft tissue of the upper arms as a result of significant weight loss. You complainof pain and hygiene issues related to the excess skin. However, specific conservative measures attempted for treatment of the hygiene issues was not documented,and it is unclear from the documentation the degree of severity present. The requesting physician only stated that there was excess. No photographs were provided. Therefore, it cannot be adequately determined if the requested surgery would likely improve yourpossible functional impairment. Brachioplasties are typically performed for cosmetic reasons. There can be instances when they are performed for reconstructive purposes, however, in this case, there were insufficient medical records.Therefore, the requested service is not medically reasonable or necessary at this time. 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 requested services have not been met.Therefore, we decided that the Plan does not have to pre-approveexcess skin removal.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic treatment (98941). You say that you would like reconsideration because the provider is in-network with Medicare. The Plan denied your request. The Plan says utilization of network providers is required when possible and available.
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 medical services provided on April 20, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forPrecepta Genomic Sequencing (81479) provided on July 18, 2020.You asked the Plan to pay forthe Precepta Genomic Sequencing. You say that you would like reconsideration because this is a Medicare covered test.The Plan denied your request. The Plan says this is not a covered benefit.The Plan follows Medicare rules. Medicare rules say that limited coverage for the PERCEPTA Bronchial Genomic Classifier is provided to identify patients with clinical low-or intermediate-risk of malignancy, after a non-diagnostic bronchoscopy.We asked our physician reviewer to carefully review the case file and applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Precepta Genomic Sequencing. Our reviewer says that the member does not meet LCD criteria for coverage. Our physician reviewer found no pathology has been submitted to show a non-diagnostic biopsy.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 Precepta Genomic Sequencing have not been met.Therefore, we decided that the Plan does not have to pay forPrecepta Genomic Sequencing (81479) provided on July 18, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecrown -porcelain fused to predominantly base metal (CPT Code D2751) and prefabricated post and core, in addition to crown, tooth #11 (D2954).You asked the Plan to pre-approvethe dental services. You say that you needto have this crown done because since the initial procedure, the crown fell off. You state you need to have this done quickly because you have a hole on your tooth.The Plan denied your request. The Plan says the tooth does not appear to have significantbreakdown due to decay or trauma.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 the dental services when the services are medically necessary and reasonable. 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 dentalservices. Our physician reviewer found you presented with a request for a crown on endodontically treated tooth #11. The tooth appears to have an existing one surface restoration. The Policy states that "B. In general, crowns are allowed only for teeth needing multi-surface restorations where amalgams and other materials have a poor prognosis. Anterior teeth must have pathologic destruction to the tooth by caries or trauma, and must involve four or more surfaces and at least 50% of the incisal edge." Also,"Crowns are not a covered benefit if: 1. A lesser meansof restoration is possible." In this instance, despite the fact there had been endodontic treatment of tooth #11, there is insufficient missing tooth structure as to require a crown restoration. The tooth is mostly intact with only an existing one surface restoration as seen on radiograph. A standard composite resin restoration would be reasonable and appropriate for this situation. Given the minimal amount of missing structure, the request for a crown on #11 does not meet the Plan criteria.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approvecrown -porcelain fused to predominantly base metal (CPT Code D2751) and prefabricated post and core, in addition to crown, tooth #11 (D2954)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe limited oral evaluation (D0140), the cone beam CT with interpretation (D0364) and the apicoectomy (D3410) provided from August 25, 2020, to September 14, 2020.You asked the Plan to reimburse you forthe dental services. You say that you were referred to this dentist by your regular dentist. You say that you did not know that he was not contracted with Medicare. You say that you were under the impression that you had out of network coverage. You also say that the services should be covered because you were not aware that the dentist could not service people who have Medicare.The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to providers who have opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to reimburse you forthe limited oral evaluation (D0140), the cone beam CT with interpretation (D0364) and the apicoectomy (D3410) provided from August 25, 2020, to September 14, 2020.
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 the enrollee needs to be admitted to the requested facility because they specialize in the care he needs.The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current facility.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital and when considered medically stable by the treating team will be a candidate for care at a less intense level such as a skilled nursing facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea Group 3 power wheelchair (PWC) with multiple power options.You asked the Planto pre-approvethe Group 3 PWC. You say that the enrollee does not have an appropriate mobility device and is chair/bed bound with severely high risk for skin breakdown due to incontinence and the inability to pressure relief or reposition or perform an independent stand/pivot transfer.The Plandenied your request. The Plansaysthe enrollee does not meet the criteria for the type of wheelchair being requested. A lower level PWC may be approved if requested.The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options is covered when the above noted criteria are met. 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 Group 3 PWC. Our reviewer says that the requirements for coverage of a PWC with multiple power options are not met in this case. Our physician reviewer found the documentation reveals the patient has a neurological condition of hemiparesis after stroke which impairs her ability to perform MRADLs in the home but the documentation does not reveal that the requested K0861 with multiple power options is necessary as the wheelchair exceeds her medical need. The patient does not require power tilt and recline. The patientis not at high risk for development of a pressure ulcer, does not use intermittent catheterization, and does not have increased tone therefore the requested wheelchair with multiple accessories is 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 Group 3 PWC have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea Group 3 power wheelchair (PWC) with multiple power options
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelaparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed (CPT Code 55866) to be performed by an out-of-network provider.You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says the member self-referred for continuity of care to this out-of-network provider and was provided with in-network options. The Plan states there is no indication that this is an urgent or emergent situation or that the member's condition or surgical procedure is so specialized that it cannot be done safely and appropriately by the plans contracted physicians and facilities.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-approvelaparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed (CPT Code 55866) to be performed by an out-of-network provider.