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

We decided that the Plan has to pay for additional inpatient hospital services provided on December 17, 2019, through January 7, 2020.
You asked the Plan to pay for the additional inpatient hospital services. You say that you would like reconsideration because these funds were recouped in error. The Plan denied your request. The Plan says that the documentation submitted does not support the services billed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has failed to forward any clinical information in order for the outlier services to be verified. Of note, the documentation submitted suggests that the Plan reviewed medical records for the services at issue. It is the burden on the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for additional inpatient hospital services provided on December 17, 2019, through January 7, 2020.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex device surgery.
You asked the Plan to pre-approve these services. You say that you have tried everything else for your pain. The Plan denied your request. The Plan says that research has not found it to be helpful for your condition or for what is causing your pain.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for your medical condition. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex device surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on May 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this reprocessed and paid due to the fact that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network physicians available to provide 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 an office visit provided on May 3, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the arm joint you had on January 14, 2020.

You asked the Plan to waive the copayment for the MRI. You say that you were told that the location where you had this MRI was a 'freestanding, outpatient facility', so no copayment should apply. 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 $50 copayment for advanced imaging at a specialist's office. 

You have been asked to pay a $50 copayment for the MRI. The facility where you had this MRI done is a
specialist's office, not a freestanding radiological facility. 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 magnetic resonance imaging (MRI) of the arm joint you had on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for lab services you received from an out-of-network provider on April 1, 2021.
You asked the Plan to waive the coinsurance for the lab services. You say that the pain clinic said they were not going to use your insurance card. You do not know what this bill is for. The Plan denied your request. The Plan says you were charged this coinsurance correctly. You received drug testing lab services from this out-of-network provider.
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 50% of the Medicare-allowed amount for out-of-network lab services.
You have been asked to pay 50% of the Medicare-allowed amount for the lab services. 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 lab services you received from an out-of-network provider on April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve pneumatic compression device. You say that this is a local durable medical equipment provider. The Plan denied your request. The Plan says the denial of authorization for this equipment is correct, because this provider is out-of-network with the Plan and this equipment can be provided by an in-network supplier.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an out-of-network (OON) provider.
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 rehabilitation. The Plan denied your request. The Plan says that your nursing, medical management and rehabilitation needs do not require an interdisciplinary team approach to delivery of rehabilitation 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for low back pain. Your medical
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: 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 you do not need daily skilled care.
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 records do not show that you have skilled nursing needs. While you need skilled therapy, you do not need it on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. You say that the enrollee has Type 2 diabetes and it is difficult for the enrollee's wife to obtain fingerstick blood glucose levels. The Plan denied your request. The Plan says that the enrollee does not meet medical necessity guidelines for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits.
You asked the Plan to pre-approve additional PT visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 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 requested therapy is not generally accepted as specific
and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy for this condition 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 by or under the supervision of a therapist. The enrollee has been already authorized therapy sessions for training for caregivers. 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 enrollee'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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and gingival irrigation (D4291) provided on May 3, 2021.

You asked the Plan to pay for the periodontal maintenance and gingival irrigation. You say that you were not aware that the provider was no longer in network. You say that you were not able to check using the member portal. You also say that the dentist did not advise that they were no longer in network either. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service. The Plan says that gingival irrigation 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 periodontal maintenance and gingival irrigation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) and gingival irrigation (D4291) provided on May 3, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient services billed with diagnosis related group (DRG) 268 that were provided from July 26, 2019, to July 31, 2019.

You asked the Plan to pay for inpatient services billed with DRG 268. You say that the services provided were medically necessary, reasonable, and appropriate for the enrollee's diagnoses and condition. You say these services were billed with the appropriate DRG. The Plan denied your request. The Plan says that DRG 268 is not supported in the record, and that DRG 269 is more appropriate as the submitted records do not support metabolic encephalopathy (G93.41) as a secondary diagnosis.

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. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient services billed with DRG 268. Our reviewer says that the submitted DRG 268 is supported in the record. Our physician reviewer found the enrollee was admitted to the hospital with an abdominal aortic aneurysm that was increasing in size. The enrollee underwent surgery, and it is documented that they were increasingly confused afterward. The clinical findings of metabolic encephalopathy can range from subtle cognitive difficulties to florid delirium or coma. While the enrollee had a known diagnosis of dementia, the documentation supports that the enrollee also had metabolic encephalopathy during the postoperative period. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient services billed with DRG 268 have been met. Therefore, we decided that the Plan has to pay for inpatient services billed with diagnosis related group (DRG) 268 that were provided from July 26, 2019, to July 31, 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: 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 records provided support that IRF care is
medically necessary. The Plan denied your request. The Plan says the criteria for coverage of IRF care have not
been met. The Plan says that IRF care is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was 
admitted for knee pain after a fall and non-surgical management of tibia and fibula fractures. 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 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 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: 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 the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that 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 your function was at or near your prior level
of function and you could be discharged to a lower level of care for further services. As of September 12, 2021,
you require custodial services. 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 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: 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 medically necessary The Plan denied your request. The Plan says an IRF admission 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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 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.