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

We decided that the Plan does not have to pay for the skilled nursing services provided from November 7, 2019, to November 20, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of coverage were not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from November 7, 2019, to November 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel testing provided on June 11, 2021.
You asked the Plan to pay for the testing services. You say that you needed to have labs done. The Plan denied
your request. The Plan says the service is non-covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and the rules. This testing is not covered by any Medicare outpatient benefit category.
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we
decided that the Plan does not have to pay for the general health panel testing provided on June 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided November 14, 2020 to
November 20, 2020.
You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the DRG billed is not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with E87.1 identified as Hypo-osmolality and
hyponatremia. 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 inpatient services. Our
reviewer says that the documentation does not support that the DRG billed is supported by the documentation.
Our physician reviewer found the documentation supported an admission for syncope related to medication
induced hypotension and bradycardia. The provider documentation did not reflect on a reason or suspected
cause for hyponatremia. The enrollee was treated with IV fluids due to dehydration. There was no mention of
any specific treatment for hyponatremia. There was no specific treatment for hyponatremia. The review has
determined that the DRG billed was not supported by the documentation. The secondary diagnosis of E87.1,
Hypo-osmolality and hyponatremia was not supported by the documentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient services provided November 14, 2020 to November 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
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 intensive therapies, consisting of at least 3 hours of therapy per
day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from
physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and low intensity
setting such as a skilled nursing facility.
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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have any complex wound care needs as well as nursing or complex medical needs. The LTACH will not add any value-based care and will not change the short- or long-term outcome. The LTACH will lead to futile unnecessary care and increased risk of complications. The enrollee can be safely managed 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 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 reduce the coinsurance for the total knee arthroplasty (27447)
provided on November 21, 2020, or pay for the self-administered drugs provided from November 21, 2020, to
November 23, 2020.
You asked the Plan to reduce the coinsurance for the knee arthroplasty and pay for the self-administered drugs.
You say that the enrollee was inpatient for these services, and you were told the cost would be lower. The Plan
denied your request. The Plan says the enrollee was outpatient status at the time of services, which is
appropriate for the knee arthroplasty procedure provided. The cost-sharing was applied correctly for the
outpatient care, and self-administered drugs are not covered by Medicare Part B.
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 20% coinsurance for each Medicare-covered visit to an outpatient hospital facility, certified
ambulatory surgical center or clinic.
The enrollee has been asked to pay 20% coinsurance for the outpatient hospital care and knee arthroplasty. The
Plan's total allowed cost for the covered services is $13,827.91. The care provided was billed as outpatient
services, and there is no documentation showing that the enrollee was admitted as an inpatient at this time. The
enrollee has been asked to pay $2,765.58 in coinsurance ($13,827.91 x 20% = $2,765.58) for the covered care.
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 reduce the coinsurance for the total knee arthroplasty (27447) and related
outpatient services provided on November 21, 2020.
In addition, 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 pay for the self-administered drugs provided during the outpatient
hospital stay from November 21, 2020, to November 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can be discharged.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary for the enrollee to regain
baseline function and to ensure safety upon returning home. You say that hospitalizing the enrollee longer
increases the risk of hospital acquired conditions such as skin breakdown, infection, and falls. The Plan denied
your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's
needs can safely be met in the current hospital 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 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 infection of the right foot and had a below the knee amputation. The enrollee's 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 enrollee has a need for physical and/or occupational therapy, there is
no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that
the 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 inpatient rehabilitation facility (IRF) admission and services.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee does not have any complex wound care needs as well as nursing,
complex medical or surgical needs. The LTACH will not add any value-based care, will lead to futile care and
will increase risk of complications. The enrollee can be safely managed 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 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 long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
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. The enrollee was admitted with acute hypoxic respiratory failure due to coronavirus and gastrointestinal bleeding. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
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 clinical documentation provided
supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of
LTACH care have not been met. The Plan says that the enrollee can safely receive the care needed in another
setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation indicating medical necessity for admission to a LTACH.
The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require
services at the LTACH that are not available at the acute care hospital where she is currently receiving care.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, thorax, diagnostic; without contrast material (CPT
code 71250), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
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 CT scan. Our physician reviewer
found there were no other clinical documents to show the indication of the CT chest being repeated or what
was found on the prior one. There was no report of tobacco use history or current signs or symptoms to justify
this request. Therefore, this request for chest CT will be considered not medically necessary at this time 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 the CT scan have not been met. Therefore, we
decided that the Plan does not have to pre-approve CT, thorax, diagnostic; without contrast material (CPT code
71250), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the OON provider on
February 2, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out-of-network
provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99213) rendered by the OON provider on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical trays provided on April 21, 2021.
You asked the Plan to pay for the surgical trays. The Plan denied your request. The Plan says no separate payment is made.
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 looked at the file and the rules. We find that CPT code A4550 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the surgical trays provided on April 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says you should
meet clinical expectations with the approved visits.
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 additional services. Our physician
reviewer found that you have a past medical history including chronic pain in the neck, low back and hip. You
have been treated with at least 20 visits of physical therapy for your condition. The documentation indicates
you have had improved parascapular and postural strengthening. You also have a home exercise program.
There is no documentation of a recent injury or decline in function. The additional therapy services are not an
appropriate duration and frequency for treatment of your condition and therefore are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does
not have to pre-approve additional physical therapy visits.