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

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 2, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from February 2, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric care from February 2, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of February 2, 2022, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond February 2, 2022, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.  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 psychiatric care from February 2, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 2, 2022, forward.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0480) provided on January 25, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility. The Plan also says that the member does not meet the exceptions, such as, an ambulance service, emergency and urgently needed, post stabilization care, nor dialysis while outside of the service area. The Plan also says that both the referring and attending providers are all non-participating with the Plan.  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 drug testing (G0480) provided on January 25, 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 IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you were fully independent before hospital admission and now you cannot do anything, transfer, walk, feed yourself or dress. You state that you could lose all functionality and ability to regain independence without fuller level of care. You state that you are not well enough to go to home health or skilled nursing facility (SNF) and you need higher level of care to regain strength and mobility. The Plan denied your request. The Plan says the plan states your records show that you do not require supervision of a rehabilitation doctor at least three times per week. The plan states you do not appear likely to improve a lot in a reasonable amount of time and you do not require aggressive therapies by an intensive team in order to properly regain your function. The Plan states you can safely receive the services you need in other settings, for example: a SNF, home with home health and home physical therapy, 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 health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to tolerate fifteen (15) hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve scaling and root planing, 4 or more teeth per quadrant, (D4341) for the upper right quadrant, and a partial upper denture (D5213).  You asked the Plan to pre-approve the dental services. You say that these services affect your eating. You also say that your teeth are getting loose, and you need your teeth. The Plan denied your request. The Plan says the requested services are not medically necessary.  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. The Plan covers the dental services when the services are medically necessary and reasonable.   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 dental services. Our reviewer says that the requested dental services are not medically necessary. Our physician reviewer found procedure code D4341 is for scaling and root planing, 4 or more teeth per quadrant. The provided documentation indicates that only 3 teeth are present in the upper right quadrant. Therefore, the requested procedure code D4341 is not medically necessary. The reviewer also found that the remaining upper teeth have significant bone loss resulting in a poor prognosis. Therefore, the reviewer found that the requested partial upper denture is not medically necessary either.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the file indicates that there are less than 4 teeth that require scaling and root planing which is necessary for the requested code. Additionally, the file indicates that your remaining upper teeth have a poor long term prognosis. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing, 4 or more teeth per quadrant, (D4341) for the upper right quadrant, and a partial upper denture (D5213).
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs 24 hour care and inpatient therapy. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.

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 enrollee does not require the intensity of services provided at an IRF.

Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services received on August 30, 2021.

You asked the Plan to waive the copayment for the services. You say that you were never seen in the emergency room. The Plan denied your request. The Plan says the claim was processed appropriately.

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 $90 copayment for emergency room services. 

You have been asked to pay a $90 copayment for the services. the services falls within the emergency room 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 emergency room services received on August 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Budesonide for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. 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 pre-approve Budesonide for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 23, 24, and 25.  You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says tooth #'s 23, 24, and 25 have lost nearly 70% of its facial bone support and gingival tissue, which renders the tooth with a very poor to hopeless prognosis. The Plan also says that this condition does not meet required clinical criteria to establish medical necessity.  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. The Plan covers the crowns when the services are medically necessary and reasonable.    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 crowns. Our reviewer says that the crowns are not medically necessary. Our physician reviewer found each of the three teeth exhibits advanced periodontal disease with more than 50% loss of supporting bone. Under the criteria, as well as general standard of care, a tooth with less than 50% bone loss has a poor long-term prognosis and would not be a proper abutment for a full coverage crown. Our reviewer found that a 1:1 crown to root ratio (50% bone loss) has been a long-established lower baseline for determining reasonable periodontal viability for an abutment. Our physician reviewer also found that in this case none of the teeth in question have a sufficient crown to root ratio to meet the Plan criteria for bone support, making the crowns not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 23, 24, and 25.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on August 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must first be
sent to the primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the
Plan does not have to pay for the services provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on January 7, 2020.  You asked the Plan to pay for the services provided. You say that the claim was initially sent to Medicare. The Plan denied your request. The Plan says the time limit for filing has expired.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the services provided was not filed until September 13, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 7, 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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower 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.  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 coronavirus pneumonia and were discharged home on January 22, 2022. 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 you have 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (26055) provided on July 27, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in the global surgery payment.
The Plan must follow Medicare rules. Medicare rules say that payment for services related to the surgery are included in the global surgery package.
We looked at the file and Medicare rules. In this case, the services in question were provided within the 90-day global surgical period of the procedure (26440) performed on June 22, 2021. Payment for the requested service is included in the payment for the global surgical procedure. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (26055) provided on July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit (Q5106).
You asked the Plan to pre-approve Retacrit. You say that the enrollee has a hemoglobin less than 10, with a
history of blood transfusions. You also say that this is urgent because the enrollee is scheduled for treatment
The Plan denied your request. The Plan says the enrollee does not meet the clinical criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for Food and
Drug Administration (FDA) approved drugs if they are medically accepted as safe and effective or appropriate
for the particular use.
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 Retacrit. Our reviewer says that
Retacrit (Q5106) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the
requested use of Retacrit (Q5106) is not FDA-approved for the enrollee's diagnosis. Our reviewer found that
the use is not supported by one of the major drug compendia or by clinical research that appears in a Centers
for Medicare & Medicaid Services (CMS) approved medical journal. Our physician reviewer also found that
the use is not listed as not indicated, not supported or not recommended in any of the compendia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have
to pre-approve Retacrit (Q5106).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for application of hot or cold packs (97010) provided from November 2, 2020, to November 5, 2020.
You asked the Plan to pay for hot/cold pack applications. You say that this code has been paid on all other claims. The Plan denied your request. The Plan says the denial of payment for these services is correct, because code 97010 is always bundled for payment and is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that code 97010 is always bundled for payment. We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of hot/cold pack applications have not been met. Therefore, we decided that the Plan does not have to pay for application of hot or cold packs (97010) provided from November 2, 2020, to November 5, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the pelvic ultrasound (76857) provided on October 5, 2021
by an out-of-network (OON) provider.
You asked the Plan to pay for the pelvic ultrasound. You say that the current procedural terminology (CPT)
code that was billed does not require authorization. You also say that you would like this claim to be
reprocessed for payment. The Plan denied your request. The Plan says a prior authorization is required for non-
contracted provider services and was not obtained.
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 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 pelvic ultrasound (76857) provided on October
5, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the sedation services provided on July 24, 2021. You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the Medicare rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT code 99153 is a technical component only code and not payable as billed. 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 sedation services provided on July 24, 2021.