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

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 an exacerbation of chronicobstructive pulmonary disease, pneumonia and congestive heart failure. Medical conditions 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. You do 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. 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-approveacute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide 8 additional physical therapy visits.
You asked the Plan to provide 8 additional physical therapy visits. You say that the enrollee needs additional physical therapy visits. The Plan denied your request. The Plan says they will provide 2 additional PT visits for transition to a home exercise plan, the remaining 8 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 provide 8 additional physical therapy visits. 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 patient has been instructed in and is compliant in a home exercise program. The therapy sessions appear repetitive. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to provide 8 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home visit services for a housekeeper.
You asked the Plan to pre-approve the home visit services for a housekeeper. You say that the enrollee lives
alone and needs a housekeeper because of her conditions. The Plan denied your request. The Plan says the
requested home assistance service is not covered under your current coverage benefits.
The Plan must follow Medicare rules. Medicare rules say that to be covered, home health aide services must be
reasonable and necessary.
We looked at the file, the Plan's rules and Medicare rules. The file shows that the Plan does not cover home
visit services for a housekeeper as a supplemental benefit. Therefore, we decided that the Plan does not have to
pre-approve home visit services for a housekeeper.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued services. You say that to return home would be a safety risk. The Plan denied your request. The Plan says that you no longer require daily skilled services in a SNF setting.
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. Continued SNF services beyond June 23, 2021, were requested. 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 services. Our physician reviewer found that you do not have documented skilled nursing needs. However, you do have documented skilled therapy needs. You are functioning below your baseline. You are making slow progress with therapy and are not shown to have reached a plateau in function. Daily skilled services are required to establish a maintenance program and to prevent deterioration of your condition. Your care needs, as a practical matter, cannot be provided at a lower 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 continued services have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis, and bitewing x-rays provided on January 19, 2021 by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation, prophylaxis, and bitewing x-rays. You say that you were not aware that this provider was OON. The Plan denied your request. The Plan says these services were performed by a non-participating provider. You are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.

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, you are responsible for a 50% coinsurance for exams, bitewing x-rays, and prophylaxis that are received OON. You are also responsible for the difference between the billed amount and allowed amount for each service received OON. The record also shows that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis, and bitewing x-rays provided on January 19, 2021 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from April 16, 2020, to June 26, 2020.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for DME and related supplies.
You received DME and related supplies from April 16, 2020, to June 26, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.
Dates of Services
Service
Allowed Amount
Amount You Owe
4/16/2020 - 5/15/2020
E2402
$2,280
$570
5/16/2020 - 6/14/2020
E2402
$2,280
$570
6/15/2020 - 6/26/2020
E2402
$2,280
$228
The total amount you owe is: $1,368. You have been asked to pay the total coinsurance amount of $1,368 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 DME and related supplies provided from April 16, 2020, to June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial denture from a provider that has opted out of Medicare.

You asked the Plan to pre-approve the partial denture. You say that you would have had the services sooner but were scheduled for major surgery in March of 2021. You say that you did not go many places due to trying to stay safe. The Plan denied your request. The Plan says the provider you are requesting these dental services from opted out of Medicare effective January 25, 2021.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal are a non-urgent, non-emergent situation and being requested from a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-approve a partial denture from a provider that has opted out of Medicare.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on November 19, 2020 and November 20, 2020.
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99291.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress notes for November 19, 2020 and November 20, 2020 do not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on November 19, 2020 and November 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA).
You asked the Plan to pre-approve genicular RFA. You say that your knee is swollen and you are in pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because genicular RFA is experimental/investigational.
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 genicular RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no higher quality studies demonstrating the long-term efficacy and possible adverse effects of this procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA).
Appeal type: SNF
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 you are ready to be dismissed to a rehabilitation facility. The Plan denied your request. The Plan says you do not meet criteria for coverage of IRF level of 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 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 you do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services and intermittent skilled services at a lower level of care. The elements of the coverage criteria are not satisfied. 
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from November 3, 2020, through December 2, 2020.
You asked the Plan to pay for the home health services. You say that the records submitted support that this care was medically necessary. The Plan denied your request. The Plan says the documentation does not include a plan of care from the treating physician.
The Plan must follow Medicare rules. Medicare rules say that home health services may be covered when provided under a plan of care established and reviewed by a physician or allowed practitioner. The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face encounter visit. In this case, the records do not include any evidence of a signed plan of care from an allowed provider. There is also no documentation of a face-to-face visit with a certifying provider. Without this documentation, criteria for payment of the home health services rendered have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from November 3, 2020, through December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bridge for teeth # 3, 4, 5, and 6 provided on October 5, 2020.
You asked the Plan to pay for the bridge. You say that you needed a new bridge. You say that you had decay under the bridge. You say that you did not realized that your plan covered bridges at the time, so you paid for it out of pocket. You also say that you are on a fixed income. The Plan denied your request. The Plan says a bridge is only covered when it is replacing 1 missing upper anterior tooth and or 2 adjacent lower anterior teeth, also when there are no missing posterior teeth in the arch.
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 bridge when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the bridge. Our reviewer says that the bridge is not medically necessary. Our physician reviewer found the provided documentation indicates that you are missing a back tooth. The reviewer found that bridges are not covered when there are back teeth missing.
Therefore, the reviewer found that the bridge is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the bridge have not been met. Therefore, we decided that the Plan does not have to pay for the bridge for teeth # 3, 4, 5, and 6 provided on October 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from February 5, 2021, to March 26, 2021.
You asked the Plan to pay for the SNF services. You say that you were not given proper notice of the services ending for the enrollee. You say that the enrollee still requires skilled rehabilitation services. You also say that the enrollee requires shots for diabetes and intravenous (IV) administration of fluids to make sure he is hydrated. The Plan denied your request. The Plan says the enrollee did not require skilled services on the dates of service in this case.
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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from February 5, 2021, to March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the catheter supplies provided on January 4, 2021.

You asked the Plan to waive the coinsurance for the catheter supplies. You say that the member should have been notified about the provider changes. 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). The enrollee's contract with the Plan clearly says that enrollees must pay 30% coinsurance for an out-of-network durable medical equipment provider. 

The enrollee has been asked to pay $311.04 which is 30% of the allowed amount for the catheter supplies. The allowed amount is $1,036.80. ($1,036.80 x 30% = $311.04). The catheter supplies fall within the "Durable medical equipment (DME) and related supplies" benefit category. The record shows the provider is out-of-network.

This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the catheter supplies provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on December 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not enrolled in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services provided on November 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the ophthalmological services. You say that a referral is not required for ophthalmology services. The Plan denied your request. The Plan says the provider is out-of-network
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 the ophthalmological services provided on November 10, 2020 by an out of network (OON) provider.