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. You say that the enrollee's ability to regain maximum function is in jeopardy if denied the benefit of inpatient rehabilitation. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the enrollee would benefit from more extended therapy, as well as skilled nursing care given their medial issues such as their glucose control and other medical issues. The Plan states the enrollee can safely receive the services they need in other settings, for example: a skilled nursing facility. The Plan states you may discuss this with the enrollee's provider.  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 available records the enrollee with Cervical spinal stenosis and Myelopathy, status post-surgery is medically stable. With the enrollee's current medical stability and comorbid conditions being stable, the enrollee does not need Physical Medicine and Rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs noted in the record. At the current functional level, the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. The enrollee is unable to take part in therapies and is max to total A and will not make a significant progress in a reasonable period of time in an IRF and benefit from it. IRF admission is not medically necessary based on lack of medical complexity, and rehabilitation nursing needs. Additionally, still lethargic, and unable to participate in physical therapy (PT). Document does not support the necessity for admission to IRF. The enrollee's rehabilitation needs can be safely met in an alternate and lower intensity setting such as in an SNF.  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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) provided March 23, 2021 to Mary 13, 2021  You asked the Plan to pay for the chiropractic services. You say that code 98943 is a non-Medicare chiropractic service but your Plan covers 24 non-Medicare chiropractic visits per year. The Plan denied your request. The Plan says this service is not a covered benefit.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) provided March 23, 2021 to Mary 13, 2021
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. You say that you have not received assistance going to the restroom. You state you do not feel comfortable asking assistance from the staff at the facility, as they have used foul language at your suite mate. You state in order to fully recover from your illness, you feel it would be best if you were moved to another facility. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the care you need can be provided in a SNF.  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 with your current medical stability and comorbid conditions being stable, you do not need Physical Medicine and Rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute or complex rehabilitation nursing needs noted in the record. You do not need intensive therapies, consisting of at least three (3) hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. IRF admission is not medically necessary based on lack of medical complexity, and rehabilitation nursing needs. Document does not support the necessity for admission to IRF. Your rehabilitation needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility (SNF).  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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the established patient domiciliary or rest home visit (99335) provided on July 14, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary or rest home visit. You say that you did not know that the facility failed to get preauthorization and you treated them anyways. Kindly review and reprocess the claim and reimburse the doctor for services rendered in good faith and best interest to the enrollee. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 the established patient domiciliary or rest home visit (99335) provided on July 14, 2021 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 hospital care.  

You asked the Plan to pre-approve acute inpatient hospital care. You say that you were approved for a lumbar decompression and will need inpatient admission after surgery. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.  

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found you are approved for a lumbar decompression. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 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 not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aid (V5257), provided on April 23, 2021.  You asked the Plan to pay for the hearing aid. You say that the item should be covered. The Plan denied your request. The Plan says you have exceeded the Plan's maximum allowance and are responsible for the remaining amount for this service.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays up to a $1,000 allowance for hearing aids every 3 years.   We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5257), provided on April 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the colonoscopy provided on August 19, 2021.  You asked the Plan to waive the copayment for the colonoscopy. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied 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 $300 copay for outpatient surgery, including services provided at a hospital outpatient facility and ambulatory surgical centers.   You have been asked to pay a $300 copay for the colonoscopy. This service falls within the outpatient surgery, including services provided at a hospital outpatient facility and ambulatory surgical centers 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 the colonoscopy provided on August 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the body movement therapy (97140), provided on August 19, 2021.  You asked the Plan to waive the copayment for the body movement therapy. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied 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 $10 physical therapy copay for outpatient rehabilitation services.      You have been asked to pay a $10 physical therapy copay for the body movement therapy. This service falls within the outpatient rehabilitation services 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 the body movement therapy (97140), provided on August 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the enrollee no longer needs care in the acute rehabilitation facility but needs SNF care to meet rehabilitation goals. You say that the enrollee is not walking. 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 be met in the current inpatient rehabilitation facility setting.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  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 there is no documentation showing that the enrollee requires skilled nursing services. The enrollee does require skilled therapy services, but not on a daily basis. The enrollee does not require the services on an inpatient basis, only in a SNF setting. Services in the home with home health care or in a long-term care facility on a part-time basis appear appropriate in this case.  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 skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight testing provided on January 26, 2021.  

You asked the Plan to pay for the testing services. You say that the test informs clinicians about which medications require dose adjustments. The Plan denied your request. The Plan says the procedure codes have not met the associated diagnosis code relationship criteria.   

The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under certain medical indications.  

We looked at the file and the rules. In this case, the records provided do not show that the testing was ordered due to clinical factors. The testing is not considered reasonable and necessary merely on the basis of a patient having a particular diagnosis. 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 GeneSight testing provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the limited oral evaluation (D0140), provided on July 28, 2021.  You asked the Plan to pre-approve the limited oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says you went to a non-participating provider.  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 the limited oral evaluation (D0140), provided on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and occlusal adjustment - limited (D9951) provided July 22, 2021.  You asked the Plan to pay for the limited oral exam and occlusal adjustment. You say that these services were necessary and would like them covered. The Plan denied your request. The Plan says these services are not covered under your 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 the limited oral evaluation - problem focused (D0140) and occlusal adjustment - limited (D9951) provided July 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the coinsurance for outpatient hospital services provided on June 14, 2021.  You asked the Plan to waive the coinsurance for outpatient hospital services. You say that the enrollee hit their maximum out-of-pocket responsibility prior to the date of service. The Plan denied your request. The Plan says that the enrollee did not hit their maximum out-of-pocket responsibility prior to the date of service.  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 rules say that the Plan must disclose to the enrollee in clear terms all cost-sharing information. The enrollee's contract with the Plan says that enrollees must pay 10% coinsurance for covered outpatient hospital services up to a maximum out-of-pocket amount of $3,200 for 2021.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit a complete summary of all amounts applied to the enrollee's maximum out-of-pocket amount for 2021. You say that the enrollee met the maximum out-of-pocket amount for 2021 and should not be charged this amount. Without a summary of the enrollee's maximum out-of-pocket amount, the Plan has not shown that its decision to apply this cost-sharing is correct or justified. Therefore, we decided that the Plan has to waive the coinsurance for the outpatient hospital services provided on June 14, 2021.    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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the neuromonitoring services provided on July 13, 2021.  You asked the Plan to pay for the services provided. You say that the codes were billed appropriately. The Plan denied your request. The Plan says the codes are not supported in the documentation.  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 codes 95885 and 95955 are not supported in the medical record. Specifically, there is a more comprehensive code that describes the services that were provided. We find that CPT code 95907 is not supported in the medical record. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the neuromonitoring services provided on July 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services provided on June 10, 2021, through June 13, 2021.  You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the billed DRG code.  The Plan must follow Medicare rules. Medicare rules say that or Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services have not been met. Specifically, the records submitted did not include any medical records. Without clinical information, we are unable to determine if the billed DRG is supported. Of note, the record indicates that the Plan requested these records. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on June 10, 2021, through June 13, 2021.
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 this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and falls associated with Parkinson's disease. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.