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

We decided that the Plan does not have to pre-approve an IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you are motivated and able to tolerate 3 hours of therapy and you need IRF services so you can get better. The Plan denied your request. The Plan says you do not require an intensive, complex, multidisciplinary approach to daily 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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. 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 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265), for the enrollee.

You asked the Plan to pre-approve the total electric hospital bed. You say that the enrollee has a semi-electric bed but you are asking for a fully electric bed so the enrollee can move the bed up and down in height. The Plan denied your request. The Plan says the total electrical hospital bed with side rail and mattress are not a Medicare covered benefit.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the total electric hospital bed have not been met. The rules say that a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265), for the enrollee.
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 you need additional rehabilitation in order to regain function. You do not have anyone to help you at home. The Plan denied your request. The Plan says the criteria for an IRF are not met. Your nursing, medical management and rehabilitation needs do not require an interdisciplinary team approach. The care you require can be provided in another setting.

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 based on your current medical stability and lack of medical complexity, there is no need for physician supervision three times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. There is no evidence that you require an intensive therapy program with three hours of therapy per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. You do not have complex nursing or medical needs requiring a resource intensive inpatient hospital setting. Documentation does not support the need for IRF care. Your rehab needs can safely be met at a less intense and alternate 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 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: Unfavorable

We decided that the Plan does not have to pre-approve bariatric surgery with inpatient admission.

You asked the Plan to pre-approve the bariatric surgery with inpatient admission. You say that the provider wants to perform a laparoscopic duodenal switch and repair a hiatal hernia at the same time. You also say that the doctor feels this will give the enrollee a chance to get her body mass index (BMI) to 35 and then the enrollee can have orthopedic surgery. The Plan denied your request. The Plan says the enrollee's records do not show that the enrollee has tried other non-surgical treatments to lose weight, and the treatments have not worked. The Plan also says that because the procedure requested is not medically necessary, the related inpatient hospital admission is also not medically 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 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 bariatric surgery with inpatient admission. Our reviewer says that the enrollee does not meet criteria for the laparoscopic duodenal switch and hiatal hernia repair. Our physician reviewer found the provided records did not clearly show a substantial effort to use nonsurgical methods to resolve the enrollee's obesity. Most cases have a strong psychological and eating behavioral component. Our reviewer found that there was no clearly documented failure of therapy or dietary modification to address this condition. Another surgery is not likely to be sufficient as these factors have not been fully addressed, shown by the fact the enrollee regained weight after prior surgery.

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 bariatric surgery with inpatient admission have not been met. Please note, because the bariatric surgery does not meet criteria, inpatient admission is also not medically reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve bariatric surgery with inpatient admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 10, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. 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 the referring provider is also 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 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 work provided on December 10, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110), lower partial denture (D5214) and extractions (D7210).

You asked the Plan to pre-approve a complete upper denture (D5110), lower partial denture (D5214) and extractions (D7210). You say that you want to appeal the denied services that are not covered under the Plan. The Plan denied your request. The Plan says the services are not covered benefits.

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 pre-approve a complete upper denture (D5110), lower partial denture (D5214) and extractions (D7210).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital on August 15, 2021 with Coronavirus pneumonia. The physical therapy notes state that you need minimal assistance with bed mobility, transfers, and walking three feet. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an outpatient hospital facility on March 29, 2021.
You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that the cortisone injection was ineffective and you did not know you would be having this procedure until you were already at the hospital. You say that you do not believe these services warrant the $350 copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $350 copayment for services at an outpatient hospital facility. You have been asked to pay a $350 copayment for the arthrocentesis procedure. The arthrocentesis procedure
falls within the services at an outpatient hospital facility benefit category. This copayment applies regardless of the outcome of the procedure. 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 arthrocentesis procedure you had at an outpatient hospital facility on March 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility services after August 19, 2021.
You asked the Plan to pre-approve continuation of skilled nursing facility services after August 19, 2021. You say that you still can't walk because of an injury. The Plan denied your request. The Plan says at the current level of function the you do not require daily skilled nursing services.
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 continuation of skilled nursing facility services after August 19, 2021. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of August 19, 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 19, 2021. The denial for further inpatient skilled care is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of skilled nursing facility services after August 19, 2021 have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of skilled nursing facility services after August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainer crowns (D6740 x5), and pontic (D6245) provided on January 20, 2021.
You asked the Plan to pay for retainer crowns, and pontic. You say that you thought the services would be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 retainer crowns (D6740 x5), and pontic (D6245) provided on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on February 10, 2021.

You asked the Plan to pay for a comprehensive oral evaluation. You say that you moved and had an appointment with a new provider. You thought the service would be covered and you were not aware of the frequency limitation. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 3 Plan years.

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.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on June 9, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on March 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. 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 lab work provided on March 19, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not have daily skilled needs.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee 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 could receive further services at a lower level of care. She requires custodial care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital on August 1, 2021. You are unable to stand. You have no skilled nursing needs. The record show that you have skilled therapy needs but would not be able to participate in daily skilled nursing services at the SNF. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on March 12, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for psychotherapy services. You say that you would like this 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 psychotherapy services provided on March 12, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a core buildup (D2950) provided on April 2, 2021.
You asked the Plan to pay for a core buildup. You say that you do not agree with the charges. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 a core buildup (D2950) provided on April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921).
You asked the Plan to pre-approve gingival irrigation (D4921). You say that you have an infection and are in massive pain. You say that the provider is recommending this treatment and the decision should be reconsidered. The Plan denied your request. The Plan says the service is not a covered benefit.
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 pre-approve gingival irrigation (D4921).