Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oral nutritional product, Glucerna (B4154).
You asked the Plan to pre-approve the oral nutritional. You say that you were denied meal replacement shakes. You have cancer and you cannot eat. This is the only thing you do eat. you would like this approved as soon as possible because this is a financial burden on you. The Plan denied your request. The Plan says oral nutritional products are not a covered benefit.
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 the oral nutritional product, Glucerna (B4154).
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 necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 comprehensive periodontal evaluation - new or established patient (D0180) provided September 24, 2020, and biologic materials to aid in soft and osseous tissue regeneration (D4265) provided October 2, 2020.
You asked the Plan to pay for the comprehensive periodontal exam and biologic materials to aid in soft and osseous tissue regeneration. You say that the services were provided during the pandemic and you cannot afford the cost. The Plan denied your request. The Plan says you have exceeded frequency limits for the periodontal exam and the biologic materials are not a covered service.
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 comprehensive oral or periodontal exam once every 36 months. We looked at the file, and Medicare rules. A comprehensive oral exam was previously covered on August 18, 2020. Based on this information, we decided that the Plan's rules frequency limit for the comprehensive periodontal exam has been exceeded. Though the Plan provides dental benefits in excess of Medicare coverage, the biologic materials to aid in soft and osseous tissue regeneration is not among those covered services. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or established patient (D0180) provided September 24, 2020, and biologic materials to aid in soft and osseous tissue regeneration (D4265) provided October 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7210) provided on March 15, 2021, by an out of network dentist.
You asked the Plan to pay for the dental services. You say that your dentist gave you a treatment plan. You say that you contacted the plan to see what services would be covered. You say that you were not told anything about services being covered differently if you went out of network. You also say that the information on the Summary of Benefits is very misleading. The Plan denied your request. The Plan says there is a $75 annual deductible for dental services, excluding preventive services and periodontal maintenance. The Plan says that fillings performed out of network have a 50% coinsurance. The Plan also says that dental services performed out of network you will be responsible for paying the difference between the dentist's fees and the Plan's dental fee schedule.
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 and extractions are listed as covered, there is a $75 deductible and 50% coinsurance that apply. These are contractual obligations you agreed to when you enrolled in the Plan's dental coverage. Additionally, out of network providers may bill you for any amount greater than what the Plan paid. Therefore, we decided that the Plan does not have to pay for the extractions (D7210) provided on March 15, 2021, by an out of network dentist.
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 necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 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 IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is required medical oversight from a physician at acute level. You state the enrollee also needs nephrology oversight that can only be done at acute rehabilitation level. 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 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 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. The enrollee was admitted for right leg cellulitis. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation
does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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-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 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 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 chest pain and has cardiac stent placed and minimally invasive aortic valve replacement. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no
documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 pay for inpatient rehabilitation for substance abuse provided from April 27, 2021, through May 5, 2021.
You asked the Plan to pay for inpatient rehabilitation for substance abuse. You say that the inpatient rehabilitation admission was medically necessary. The Plan denied your request. The Plan says the admission does not meet the Medicare NCD 130.7 coverage criteria for treatment at the inpatient detox level.
The Plan follows Medicare rules. Medicare rules say that when it is medically necessary for a patient to receive detoxification and/or rehabilitation for drug substance abuse as a hospital inpatient, coverage for care in that setting is available. 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 inpatient rehabilitation for substance abuse. Our reviewer says that the inpatient rehabilitation admission does not meet Medicare coverage criteria. Our physician reviewer found that the enrollee is a 45-year-old with a history of weekly crack cocaine use and regular alcohol use last used April 25, 2021. Inpatient rehabilitation for substance abuse was provided to the enrollee from April 27, 2021, through May 5, 2021. The enrollee was admitted with mild shortness of breath (oxygen saturation of 97%) and wheezing and received a bronchodilator with benefit. There was no evidence of alcohol or cocaine withdrawal symptoms or signs on admission or during the stay. The enrollee's vitals were stable and there were no signs of dehydration, arrhythmia, altered mental status, suicidal or homicidal ideation, or any other indication which might warrant inpatient services. Therefore, without sufficient acute findings or symptoms the Medicare NCD 130.6 and 130.7 coverage criteria has not been met based on the provided documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient rehabilitation for substance abuse have not been met. Therefore, we decided that the Plan does not have to pay for inpatient rehabilitation for substance abuse provided from
April 27, 2021, through May 5, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be medically necessary for the enrollee's condition. The Plan denied your request. The Plan says SNF care is no longer 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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that as of August 7, 2021, the member did not require any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of August 7, 2021. The member received skilled care and improved; however, her function had plateaued by August 7, 2021, and she did not require any further inpatient skilled rehab services. The member's function was at or near her prior level of function and she could be discharged to a lower level of care for further 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 the continuation of SNF care. have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (27486) provided on March 6, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 27486 is not supported by the records provided. Our reviewer found that the operative report documents a total knee polyethylene exchange was performed. This procedure should be billed with modifier 52 appended to indicate the procedure was reduced. Therefore, CPT 27486 would not be covered.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (27486) provided on March 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services (99233) provided February 14, 2021 to February 16, 2021.
You asked the Plan to pay for the subsequent hospital care. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not contain documentation to support the coding criteria for code billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99233 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed
interval history; A detailed examination; Medical decision making of high complexity. We asked our coder 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 subsequent hospital care. Our reviewer says that the records do not support the billed CPT codes for the dates of service. Our reviewer found the documentation submitted did not include notes for date of service January 13, 2021, and therefore cannot be confirmed as performed. For dates of service January 14, 2021 and January 15, 2021 the documentation supports problem focused history, comprehensive exam, medical decision making of low complexity, therefore a more appropriate code to report is CPT 99231 for these dates of service. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services (99233) provided February 14, 2021 to February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection provided by a participating provider on February 15, 2021, to May 24, 2021.
You asked the Plan to waive the copayment for an injection. You say that you do not agree with all these charges. The Plan denied your request. The Plan says the correct copayments have been 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 Medicare Part B prescription drugs/in-network. You have been asked to pay a $50 copayment for an injection. The total amount you are being asked to pay is $1,100 ($50 x 22 injections = $1,100). An injection falls within the Medicare Part B prescription drugs/in-network 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 an injection provided by a participating provider on February 15, 2021, to May 24, 2021.
This appeal is for dates of February 15, 2021, to May 24, 2021. Please contact the Plan for additional dates of services in question
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the leuprolide acetate suspension provided
on November 23, 2020.
You asked the Plan to waive the coinsurance for the leuprolide acetate suspension. You say that the doctor has
been giving you hormone chemotherapy and you want to know why you should pay the claim. The Plan denied
your request. The Plan says the coinsurance 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 15% of
the cost for Medicare Part B prescription drugs.
You have been asked to pay $212.11, which is 15% of the allowed amount for the leuprolide acetate
suspension. The allowed amount is $1,414.04 (15% x $1,414.04 = $212.11). The leuprolide acetate suspension
falls within the "Medicare Part B prescription drugs" 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
coinsurance for the leuprolide acetate suspension provided on November 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (87506) provided on January 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 87506 is not supported by the records provided. Our reviewer found that this procedure was reported with diagnosis code R19.7. Per CMS, only certain diagnosis codes are approved for this procedure. This is not an approved code.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (87506) provided on January 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve outpatient mental health therapy. You say that you would like to receive individual therapy and not group. The Plan denied your request. The Plan says there are in-network providers available for 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 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 outpatient mental health to be provided by an out-of-network (OON) provider.