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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you feel that you need to be cared for in the SNF setting. The Plan denied your request. The Plan says criteria for SNF care 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 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 the member has stabilized medically and is ready for discharge from the hospital. She does not require skilled nursing and/or skilled therapy services on a daily basis. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the brain and the CT scan of the cervical spine provided on November 9, 2020.
You asked the Plan to pay for the CT scan interpretations. You say that these services are clearly documented and should be paid. The Plan denied your request. The Plan says the imaging is dated for November 8, 2020. As such, payment cannot be made for this with a November 9 date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. It is noted that second interpretations of diagnostic imaging may be covered with use of modifier -77 only in unusual circumstances for which documentation is provided. In this case, it is noted in the record that the billing provider personally reviewed the images taken the day prior on the date of service in question. However, the report in the file is signed by the radiologist. A complete separate report from the billing provider is not present, and no documentation was provided for why a second interpretation would be necessary. Based on this information, we decided that Medicare rules for coverage of the CT scan interpretations have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the brain and the CT scan of the cervical spine provided on November 9, 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 IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF 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 that the patient was admitted to an acute care hospital for respiratory failure. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive hearing test provided on
January 27, 2021.
You asked the Plan to waive the copayment for the comprehensive hearing test. You say that you were told you
and one free hearing test per year. You say that you used a network provider, and you are not at fault. The Plan
denied your request. The Plan says the copayment 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 $20
copayment for Medicare-covered diagnostic tests and procedures.
You have been asked to pay a $20 copayment for the comprehensive hearing test. The comprehensive hearing
test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The
records show this was a diagnostic hearing test. 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 the
comprehensive hearing test provided on January 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider
on March 23, 2020.
You asked the Plan to pay for the laboratory services. You say that you are submitting medical records for
reconsideration of payment. The Plan denied your request. The Plan says prior authorization was required but
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 laboratory services provided by an out-of-network
provider on March 23, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from November 6, 2020, to November 9, 2020.

You asked the Plan to waive the copayment for the emergency room visit. You say that you are not paying this bill. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

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 $90 copayment for each Medicare-covered emergency room visit.

You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit 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 the emergency room visit provided from November 6, 2020, to November 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on February 4, 2021.
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that 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 outpatient hospital services provided on February 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the bilateral lateral
sacral branches.
You asked the Plan to pre-approve the RFA. 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 pre-approve the RFA. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that RFA of the lateral sacral branches is considered experimental/investigational because of the wide
variation in efficacy in peer reviewed literature. Therefore, the request is considered not medically reasonable
or 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 RFA have not been met. Therefore, we decided that the Plan does not have
to pre-approve radiofrequency ablation (RFA) of the bilateral lateral sacral branches.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endocrinology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON endocrinology services. You say that you do not like the current in network endocrinologist you have seen and that the requested OON endocrinologist would be convenient since he is across the street. The Plan denied your request. The Plan says there are contracted endocrinology providers within the network that can treat the enrollee.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve endocrinology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on December 31, 2020.

You asked the Plan to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) and electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (99310). You say that the Plan should pay this claim. The Plan denied your request. The Plan says a modifier was not billed on the claim to represent the services as separate/distinct.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.

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 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) and Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (99310) Our reviewer says that the claim was submitted incorrectly. Our physician reviewer found the documentation submitted was reviewed and does not meet criteria. These services should be reported with modifier 59 Distinct Procedural Service, to clarify that these services are distinct from the prior claim for same date of service.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) and electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (99310) have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on December 31, 2020.
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 enrollee could definitely benefit from physical rehab offerings which aren't available in the current short-term acute care setting. The Plan denied your request. The Plan says the records do not show that it is medically necessary for the enrollee to be in a LTACH in place of an acute care hospital.
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 improving but is still unstable, requiring additional short-term acute care services that can safely be administered at the current facility for now. 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 to a lower level of care may be considered soon when treatment has completed and she is more stable. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health skilled nurse visits.
You asked the Plan to pre-approve continued home health skilled nurse visits. The Plan denied your request. The Plan says there is no longer a skilled need.
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 continued home health skilled nurse visits. Our reviewer says that continued home health skilled nurse visits are not medically necessary. Our physician reviewer found based on the documentation provided, it is my opinion that the health Plan's denial should be upheld. You do not have documented skilled nursing needs. As such, home health nursing services are not shown to be medically necessary or reasonable. 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 home health skilled nurse visits have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health skilled nurse visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure.
You asked the Plan to pre-approve Ensure. You say that your primary physician has full knowledge of your need for Ensure, because you do not eat. You say that you are underweight and need these formulas to help your nutrition. You say that you do not eat meat because you suffer from gout. You say that you suffer from anemia and have prostate cancer. You say that, because the of intense radiation you receive, your anemia levels are severe. The Plan denied your request. The Plan says oral enteral nutrition supplements are not a covered benefit through Medicare or your Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Ensure.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by on April 17, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 17, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount beyond the eyewear allowance for eyeglasses provided on March 2, 2021.
You asked the Plan to pay an additional amount beyond the eyewear allowance for the eyeglasses. The Plan denied your request. The Plan says that the claim processed correctly toward the eyeglasses benefit with the allowance of $200.00.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan processed the claim correctly with the eyeglasses benefit allowance of $200.00. Therefore, we decided that the Plan does not have to pay an additional amount beyond the eyewear allowance for eyeglasses provided on March 2, 2021.
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 enrollee requires long term acute care which is best provided in the LTACH setting. The Plan denied your request. The Plan says an LTACH cannot provided clinically superior care than 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 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 necessitating admission to a LTACH. 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 he is currently receiving care. Therefore, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953 x 2), the initial 15
minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223 x 2), the therapeutic
parenteral drug (D9610), the drugs or medicaments (D9630), and the application of desensitizing medicament
(D9910) provided on April 12, 2019.
You asked the Plan to pay for the dental services. You say that there were no in network dentists available, so
you went out of network. You say that according to the Plan's 2019 Coverage Package, "cost sharing for
necessary urgently needed services furnished out of network is the same as for such services furnished in
network." You say that a plan representative advised the provider was responsible to refund your balance. You
also say that you should be reimbursed $1,701.03. The Plan denied your request. The Plan says the services
you received are not listed as 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 bone
replacement graft (D7953 x 2), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of
deep sedation (D9223 x 2), the therapeutic parenteral drug (D9610), the drugs or medicaments (D9630), and
the application of desensitizing medicament (D9910) provided on April 12, 2019.