Persius/hicric huggingface dataset:
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 would like reconsideration because the IRF services are medically necessary. The Plan denied your request. The Plan says the member's needs may be met at a different level of 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. Our physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member's medical problems are stable. There are no complex nursing or rehabilitation needs. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this member 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services.
You asked the Plan to pay for out of network services. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says your required treatment can be provided in 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 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 out of network physician services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 1, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a respiratory screening panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76705) provided on April 1, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705
has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for the services (76705) provided on April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the core build up (D2950), localized
delivery of antimicrobial agents (D4381 x 5), the unspecified periodontal procedure (D4999 x 4), and sedation
(D9248) provided on March 5, 2020.
You asked the Plan to pay an additional amount for the core build up, localized delivery of antimicrobial
agents, unspecified periodontal procedure, and sedation. You say that this claim was filled in a timely manner.
The Plan denied your request.
The Plan says the core build up, localized delivery of antimicrobial agents, unspecified periodontal procedures,
and sedation are not listed as covered services. The Plan also says there is no record that you or the enrollee
contacted the plan to verify benefits prior to the date of service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services are not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay an additional amount for
the core build up (D2950), localized delivery of antimicrobial agents (D4381 x 5), the unspecified periodontal
procedure (D4999 x 4), and sedation (D9248) provided on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on March 3, 2021.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says the hearing aids were not purchased through the Plan hearing vendor.
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 for hearing aids only when they are received from the Plan's hearing vendor. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids were not purchased from the Plan's hearing vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on March 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve revascularization of lower extremity (37220, 37221,
37224, 37225, 37226, 37227) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the member does not have evidence of vascular disease on the left
leg.
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. The documentation
does not support the medical necessity for endovascular intervention on the left lower extremity. The patient
has a normal ankle brachial index (ABI) and no evidence of hemodynamically significant stenosis by duplex on
the left. While diagnostic angiography of the lower extremities and intervention on the right is reasonable, there
is no indication for concurrent revascularization of the left lower extremity. Our physician reviewer found that
the enrollee's 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 revascularization of lower extremity (37220, 37221, 37224, 37225, 37226, 37227) for the
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for patient of extreme age coded as 99100
provided on February 23, 2021.
You asked the Plan to pay for the anesthesia for patient of extreme age. You say that you would like this claim
reprocessed based on the medical records. The Plan denied your request. The Plan says this code has a status
indicator of B meaning that this service is always bundled into another service or procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).
We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status
indicator of B meaning that payment for this service is always bundled into another procedure. Separate
payment is not made for CPT code 99100. Based on this information, we decided that Medicare rules for
coverage of the anesthesia for patient of extreme age have not been met. Therefore, we decided that the Plan
does not have to pay for the anesthesia for patient of extreme age coded as 99100 provided on February 23,
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because the SNF admission is medically necessary. The Plan denied your request. The Plan says you can receive the same care in your current 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have made slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. You can continue to receive skilled rehab services at the current inpatient rehabilitation facility or be stepped down to a lower level of care when appropriate. There are no services offered at a SNF that are not offered at an inpatient rehab 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) admission.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of 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. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional services. You say that the enrollee has difficulty with gait,
balance, and stability. The Plan denied your request. The Plan says updated progress notes are required to
determine medical necessity of additional visits.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
The file shows that 24 physical therapy visits were requested. The Plan has agreed to pre-approve 10 visits. 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 the additional requested therapy is not generally accepted as specific and effective therapy
for the patient's condition beyond what was approved by the health plan.
At this time the records do not demonstrate that the unique skills of a professional therapist are required to
provide treatment, or that the services can be performed only by a therapist or under the supervision of a therapist for the additional therapy. The need for ongoing skilled therapy beyond what was approved by the
Plan is not documented at this time. The specialized skill of a qualified therapist is not required to establish,
design, or deliver a program to maintain her 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 services have not been met. Therefore, we decided that the Plan does
not have to pre-approve additional physical therapy services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 2, 2020.

You asked the Plan to pay for the lab services. You say that the specimen's received are from providers and
were processed without delay. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

We looked at the file and the rules. The claim lists a place of service code as an independent laboratory. The
records provided do not indicate the specimen at issue was obtained at an independent laboratory. Based on this
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we
decided that the Plan does not have to pay for the lab services provided on November 2, 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 you would like reconsideration because the IRF services are medically necessary. The Plan denied your request. The Plan says the member's needs may be safely met in a different level of 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. Our physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member's medical problems are stable. There are no complex nursing or rehabilitation needs. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this member 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of 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. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.

You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says the approved visits will allow for a home exercise program.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

The file shows that 16 physical visits were requested. The Plan has agreed to pre-approve 8 visits. 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 the enrollee is noted on objective measurements to have improved her gait speed/pattern and overall improvements in balance, gait and stairs. She still has lower left extremity strength deficits and is a fall risk.

The additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the Plan. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment or that the services can be performed only by a therapist, or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program. The specialized skill of a qualified therapist are not required to establish, design or deliver a program to maintain her 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 11, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a respiratory screening panel, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for the laboratory services rendered on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on June 24, 2021
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 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 out of network
physician services provided on June 24, 2021