Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the enrollee does not
require complex medical management and would not be able to tolerate 3 hours of skilled therapy.
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 physician reviewer found
that you have a past medical history of COPD, diabetes, hypertension, obesity and frequent falls. You are living
at home with trouble ambulating and debility. Your medical problems are stable. There are no complex nursing
needs. 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. While the medical record supports a need for
physical and/or occupational therapy, there is no documented need for intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 5, 2019, through June 7, 2019.

You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission was medically necessary. The Plan denied your request. The Plan says that the enrollee could have been cared for at a lower level.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 5, 2019, through June 7, 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for special EEG tests (95955) continuous intraoperative neurophysiology monitoring (G0453) needle electromyography (95861) evoked potentials and reflex testing procedures (95938) provided June 21, 2019.

You asked the Plan to pay for the outpatient services. You say that the plan's decision to deny your claim for past timely filing is not justified. Your records indicate that the claim was filed timely. The Plan denied your request. The Plan says this claim was received past the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the outpatient services was not filed until August 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for special EEG tests (95955) continuous intraoperative neurophysiology monitoring (G0453) needle electromyography (95861) evoked potentials and reflex testing procedures (95938) provided June 21, 2019.
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 admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require ongoing skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no complex wound care or other skilled nursing need. The enrollee has had extensive prior therapy and the enrollee's functional level does not require ongoing skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a daily basis or as a practical matter on an inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five (5) additional PT visits.
You asked the Plan to pre-approve five (5) additional PT visits. You say that you have had some bad falls recently your doctor did not feel that the three visits were sufficient to stop receiving therapy. The Plan denied your request. The Plan says you do not meet the Medicare guidelines for continued physical therapy visits in your home or that you require the skills of a physical therapist to care for your condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the five (5) additional PT 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 additional therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. You can transition to an independent home exercise program. 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 your 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 the five (5) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve five (5) PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on July 20, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the customer service representative did not advise that this dentist was OON. The Plan denied your request. The Plan says services performed by an OON provider are not covered because the enrollee's healthcare plan does not have OON benefits. The Plan also says that no contacts were made to the Plan to verify benefits or eligibility prior to the date of 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. Though the Plan offers a dental benefit in excess of Medicare coverage, enrollees are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on July 20, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal injection provided on December
24, 2020.
You asked the Plan to waive the copayment for the spinal injection. You say that you did not go to the hospital.
You say you are on a limited income and do not feel like you should be paying $250 for a shot. 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 $250
copayment for covered surgical services at an outpatient hospital.
You have been asked to pay a $250 copayment for the spinal injection. The spinal injection falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The record shows you were billed by the outpatient hospital. 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 spinal injection provided on December 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Latuda 60mg tablets (J8499).
You asked the Plan to pre-approve Latuda. You say that Latuda is medically necessary. The Plan denied your
request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.
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 Latuda 60mg tablets
(J8499).
Benefits for Latuda 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care for an elective right abductor tendon tear surgical repair, for the enrollee.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is necessary. The Plan denied your request. The Plan says the stay is not necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. The enrollee is undergoing a planned right abductor tendon repair. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 27299 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay. If the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care for an elective right abductor tendon tear surgical repair, for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services (80061, 36415, 80053, 85025) provided September 14, 2020.
You asked the Plan to waive the copayment for the lab services. You say that the cost of the labs should be paid as it was part of a physical. The Plan denied your request. The Plan says the correct copayment 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 $20 copayment for diagnostic tests. You have been asked to pay a $20 copayment for the lab services. The lab services fall within the diagnostic tests 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 lab services (80061, 36415, 80053, 85025) provided September 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that the requested Retacrit is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for Retacrit.
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 Retacrit. Our reviewer says that the enrollee does not meet criteria for Retacrit. Our physician reviewer found Medicare requires baseline labs for the coverage of Retacrit. This includes an erythropoietin level to indicate responsiveness to EPOs. There is no evidence provided that this has been accomplished. The service is not reasonable or 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 Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular electro-acupuncture nerve stimulator.
You asked the Plan to pre-approve the auricular nerve stimulator. You say that it is felt this would be helpful as a treatment to help your pain. The Plan denied your request. The Plan says this is not a covered device.
The Plan must follow Medicare rules. Medicare rules say that auricular nerve stimulators are considered electro-acupuncture devices which are noncovered by Medicare. Therefore, we decided that the Plan does not have to pre-approve an auricular electro-acupuncture nerve stimulator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on April 2, 2020, by an OON provider.
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and paid. The
Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician. The Plan says that 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 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 had network providers
available who could have provided 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 lab services provided on April 2, 2020, by an
OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0483) provided July 9, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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. We find that CPT code 80307, G0483 is not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service described in the records. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307, G0483) provided July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on July 9, 2020, to July 16, 2020 by an out of network (OON) provider.

You asked the Plan to pay for wound care. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 had network providers available who could have provided 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 wound care provided on July 9, 2020, to July 16, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) as defined by codes
es L0650-KX, L1851-LT-KX, L2397-LT-KX, L1851-RT-KX, L2397-RT-KX, L3960-LT, E0745-NU-KX and
A4595-NU-KX for the date of service July 29, 2020
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request.
The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's
condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to
pay for the durable medical equipment (DME) as defined by codes es L0650-KX, L1851-LT-KX, L2397-LTKX,
L1851-RT-KX, L2397-RT-KX, L3960-LT, E0745-NU-KX and A4595-NU-KX for the date of service
July 29, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service (D1999), the porcelain onlay (D2644), and the core build up (D2950) provided from December 31, 2020, to January 12, 2021.
You asked the Plan to pay for the unspecified preventive service, onlay, and core build up. You say that a plan representative advised that you could use this dentist and it would be covered by insurance. The Plan denied your request. The Plan says the unspecified preventive service is not listed as a covered service. The Plan says that porcelain onlay is not listed as a covered service. The Plan says core build up is not listed as a covered service either.
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 unspecified preventive service (D1999), the porcelain onlay (D2644), and the core build up (D2950) provided from December 31, 2020, to January 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic test provided by a participating provider on November 13, 2020.
You asked the Plan to waive the copayment for a diagnostic test. You say that the scan did not even show anything. You say that this caused you pain. The Plan denied your request. The Plan says the correct copayment has 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 $125 copayment for outpatient diagnostic tests/other diagnostic procedures. You have been asked to pay a $125 copayment for a diagnostic test. The correct copayment has been applied to the tests that were provided. A diagnostic test falls within the outpatient diagnostic tests/other diagnostic procedures 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 a diagnostic test provided by a participating provider on November 13, 2020.