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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 there is no documentation provided indicating medical necessity for the requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
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-approve long term acute care hospital (LTACH) services.
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 the IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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 based on the records, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care for the enrollee.
You asked the Plan to pre-approve inpatient mental health care. You say that inpatient mental health care is
medically necessary for the enrollee.
The Plan denied your request. The Plan says court ordered care is not covered by Medicare or the Plan.
Maximus overturned the Plans denial stating inpatient mental health care is medically necessary. The Plan
requested a reopen and stated that the issue was not medical necessity, but that court ordered involuntary care
ordered by a government entity is not covered by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that inpatient psychiatric
admission that are court ordered or involuntary are not covered. The records show this was a court ordered
inpatient mental health admission which is not covered by Medicare. Therefore, we decided that the Plan does
not have to pre-approve inpatient mental health care for the enrollee.
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 when the enrollee is discharged no one will be able to care for him. You say that the family are not able to take care of him and he needs rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of admission to skilled nursing facility does not meet the requirements for approval.
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 the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of chronic medical problems. His physical function is at or near his new baseline and he can receive services at a lower level of care. He has not been willing or able to participate in therapy services while in the hospital. Admission to a SNF for inpatient skilled rehabilitation services 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve the additional physical therapy. You say that you would like reconsideration because the additional physical therapy is medically necessary. The Plan denied your request. The Plan says it currently appears that the enrollee is at a functional plateau.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 additional physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found clinical documentation does not support the need for the therapeutic exercises beyond the 20 visits provided. The expectation does not exist that ongoing physical therapy will result in the practical improvement in her level of function within a reasonable and predictable period and does not need the service by a skilled therapist. 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 additional physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Outpatient Mental Health
Decision: Partially Favorable

You asked the Plan to waive the cost-sharing for office visit. You say that this service should be covered. The
Plan says that the cost-sharing amounts you are being charged are correct.
We decided that the Plan has to waive the coinsurance for office visit.
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 does not say in clear and accurate terms
how much you should expect to pay for outpatient mental health care after the 2021 deductible has been met.
We looked at your contract with the Plan. We did not see where the contract clearly discloses that enrollees must pay 20% coinsurance for outpatient mental health care. The Plan contract says that you may pay 0% to 20% coinsurance but does not clearly disclose when you should expect to pay 20% coinsurance for outpatient mental health care. The Plan contract does not clearly say how much enrollees must pay for outpatient mental health care. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the cost-sharing for office visit.
We also decided that the Plan does not have to waive the deductible for office visit.
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 $203 deductible for mental health specialty services. At the time this claim was processed, $141.76 of the $203 deductible and $464.69 of the $7,550 maximum out-of-pocket amount for 2021 had been met. The allowed amount of this claim is $119.89, resulting in a deductible amount of $61.24 because this meets the $203 total deductible amount for 2021. Therefore, we decided that the Plan does not have to waive the deductible for office visit.
Therefore, we decided that the Plan must reduce your total cost-sharing responsibility for this visit from $72.97 to $61.24.
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 the services re medically necessary. The Plan denied
your request. The Plan says coverage criteria has 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 based on the records provided, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 24, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are
not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab
services provided on November 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital clinic visit provided on February 19, 2021.

You asked the Plan to pay for a hospital clinic visit. The Plan denied your request. 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. These services are not urgent or emergent, nor were they approved in advance.

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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a hospital clinic visit provided on February 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve physical therapy. You say that these additional visits are medically necessary. The Plan denied your request. The Plan says the denial of authorization for these services are correct, because these visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found there is no documentation that the requested therapy is generally accepted as specific and effective for the enrollee's condition. The enrollee appears to have plateaued and demonstrates low motivation to initiate and complete tasks independently. Further skilled therapy at this point does not appear likely to achieve any significant improvement in symptoms or functional status. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment and that the services can only be safely and effectively performed by a therapist or under the supervision of a therapist. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 there is no documentation provided indicating medical necessity for the requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. 

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-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the SNF admission 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 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (21931) provided February 24, 2021.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the billed services.
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 21931 is Excision of a tumor from the soft tissue of back
or flank in the subcutaneous; 3 cm or greater.
We find that CPT code 21931 is not supported in the medical record. Specifically, there is a more appropriate
code that should be reported for the removal. Sebaceous cysts are dermal in origin, even if they extend into the
subcutaneous tissue, and therefore, are not considered soft tissue tumors. Based on this information, we decided
that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan
does not have to pay for surgical services (21931) provided February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 31, 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 the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on December 24, 2020.
You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request. The Plan says this was not billed with the correct place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing (G0483) provided on December 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical and occupational therapy services.
You asked the Plan to pre-approve the physical and occupational therapy services. You say that the records provided support the need for continued therapy. The Plan denied your request. The Plan says at this time the enrollee requires less than 50 percent assistance and is able to do mobility with full weight-bearing on the lower extremities. The Plan says that these functions can be carried out at home with a home exercise program with the assistance of a caregiver.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 physical and occupational therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has previously been treated with inpatient and outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition without an updated functional capacity evaluation and new goals set forth therefore the current request for additional therapy sessions 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 physical and occupational therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve physical and occupational therapy services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 admission 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 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on August 11, 2021 for failure to thrive. She has no documented nursing needs. She does not require skilled nursing on a daily basis. She is at a standby/contact guard assist level for therapy and does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.