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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not 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 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 preapprove
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 documentation does not support
that the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care. Based on the documentation provided,
the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern as to
whether the enrollee will be able to fully participate in, and benefit from, the intensive rehabilitation therapy
program provided in an inpatient rehabilitation facility. Medicare coverage criteria are not met. We looked at
this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules
for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve
acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 has network providers available who can provide 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 physician services provided on February 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained.
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 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 physician services provided on November 26, 2019 by an out of network (OON) provider.
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. The Plan denied your request. The Plan says you do not require an interdisciplinary approach for rehab care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it ismedically 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 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 were admitted for surgery for metastatic lesions of the liver. Post-operative course was complicated by bile leak and small pulmonary embolism. Your medical conditions are now stable. There are no complicated nursing or wound care needs. There is no documentation that shows you require management three days a week by a rehabilitation physician. While you do have a documented need for physical and occupational therapy, the medical record does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you willbe able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.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 reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, you do not require daily skilled nursing services or daily skilled therapy services at an inpatient 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional rides. The Plan denied your request. The Plan says that you have exceeded the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of thirty-six (36) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
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 enrollee needs physical therapy so she won't
form blood clots. The Plan denied your request. The Plan says the enrollee does not need intensive rehab,
physician supervision, or a multidisciplinary team for 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 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 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. She had a fracture of the left
hip, treated non-operatively. All chronic medical conditions are stable. There is no complex nursing or wound
care needs. There is no documentation that the enrollee requires management three days a week by a
rehabilitation physician. While she does have a documented need for physical and occupational therapy, the
medical record does not support a need for an intensive rehabilitation therapy 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services provided December 26, 2019 to December 28, 2019.
You asked the Plan to waive the copayment for the Emergency Room Services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for Emergency Care. You have been asked to pay a $50 copayment for the Emergency Room Services. The Emergency Room Services falls within the Emergency 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 for Emergency Room Services provided December 26, 2019 to December 28, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on June 27, 2019.You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and was medically necessary for management of the enrollee's condition.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because the ordering provider did not submit progress notes needed to determine the clinical utility of the testing.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered.Under Medicare rules, this means genetic testing is considered approved by the plan.Therefore, we decided that the Plan has to pay for genetic testing provided on June 27, 2019.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for right knee arthroscopic guidance provided to the enrollee on February 5, 2020.You asked the Plan to pay for the guidance. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee had known joint disease, and had no documented medical need for a diagnostic procedure.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 guidance. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found imaging guidance for visco supplementation is rarely required due to the simplicity of knee injections with physical palpation of the anatomy and typically ultrasound is used, not arthrography. In the case of this enrollee, although they had excess knee adipose tissue and severe narrowing of the joint space which helps justify consideration for imaging guidance, however, there was no report of prior failure of non-guided injections to the right knee, nor was there a noted contraindication to using ultrasound guidance instead of arthrogram. Therefore, this request for such 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 guidance have not been met.Therefore, we decided that the Plan does not have to pay for right knee arthroscopic guidance provided to the enrollee on February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Forteo (J3110).
You asked the Plan to pre-approve the Forteo. You say that you would like reconsideration because this is a medically indicated and necessary therapy. The Plan denied your request. The Plan says this drug is not covered for the member's condition by Medicare Part B.
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 Forteo (J3110).
Benefits for the Forteo 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on September 23, 2019.You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a lab order and results for the test code billed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided on September 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 the drug testing services provided on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on July 11, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by a provider who is licensed as an acupuncturist, not a physician.
The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of this service have not been met. Specifically, the acupuncture treatment was not provided by a physician licensed to perform the service. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on July 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on October 1, 2019.
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 billed are not supported by the documentation.
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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation did not support evidence of an established relationship between the enrollee and the ordering physician. 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 G0482 provided on October 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 20, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received ambulance services provided on November 20, 2019. Your EOC states, enrollees must pay a $265 copayment per date of service regardless of the number of trips. The Medicare-allowed amount for the ambulance services is less than the set $265 copayment; therefore, you have been asked to pay the lesser amount of $115.92 for the ambulance services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.You asked the Plan to pre-approve continued inpatient psychiatric services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are 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 continued inpatient psychiatric services. Our reviewer says that the documentation does not support that the requested continued inpatient psychiatric services are medically reasonable or necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on June 3, 2020 with Schizoaffective Disorder, Depressed Type. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as the enrollee did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. The documentation does not support that it is medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question, as the enrollee did not have dangerousness to self or others but was compliant with treatment. The enrollee was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. Therefore, the enrollee does not meet criteria for the requested continued services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services