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

 We decided that the Plan does not have to pay for diagnostic services (87481, 87496, 87500, 87529, 87532, 87640, 87653, 87798) provided on August 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for diagnostic services. You say that you were unable to obtain prior authorization because you are not a contracted provider. You also say you provided services in good faith that you would be reimbursed and that the patient's physician ordered the service due to the patient's history of chronic urinary tract symptoms that have failed to resolve with standard treatment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services were not urgent or emergent, nor were they approved in advance.  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 diagnostic services (87481, 87496, 87500, 87529, 87532, 87640, 87653, 87798) provided on August 17, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on January 18, 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 services are 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 cardiovascular risk assessment 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 January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing care provided on August 10, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the subsequent nursing care. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the subsequent nursing care provided on August 10, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the breast ultrasound (76641) provided on July 26, 2021.  You asked the Plan to pay for the breast ultrasound. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says the provided reports to not support that a second ultrasound was rendered.  The Plan must follow Medicare rules. Medicare rules say that for 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 breast ultrasound have not been met. Specifically, the record indicates that the Plan previously paid for CPT code 74461 LT for the same date of service.    The documentation submitted does not support that an additional ultrasound was rendered on this date of service. Therefore, we decided that the Plan does not have to pay for the breast ultrasound (76641) provided on July 26, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the enrollee.  You asked the Plan to pre-approve a CGM. You say that the enrollee needs this because she has mechanical issues with finger sticks. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of a CGM.  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. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the enrollee.
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 enrollee requires inpatient rehabilitation, and the necessary care cannot be adequately provided in a lower level of care. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's needs can be met in an alternate setting.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, 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 with regular physician evaluation. The enrollee's 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite (D2391) provided on September 10, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the resin-based composite. You say that you thought this provider was in-network because you checked and were told the dentist did accept your insurance. You also say that you think all dentists should be covered and this service should also be covered. The Plan denied your request. The Plan says this service was rendered by an OON provider. The Plan also says that you were not referred to this OON provider by an in-network provider, and you self-referred.  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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2391) provided on September 10, 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 rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation is medically necessary for the enrollee to return to their prior level of function. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's needs can be met in 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.  Our physician reviewer found based on the medical records provided, 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 does require physical therapy and occupational therapy services but does not appear to require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation program provided at an IRF due to reported confusion and the degree of their functional limitations. Care at the skilled nursing facility level appears to be 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 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 LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the health plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an acute care hospital (ACH) following thoracic surgery. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care (LTC) needs.     We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH 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 you need these services to get your strength back. The Plan denied your request. The Plan says that you can safely receive the services you need 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 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 stroke and pulmonary embolism and was discharged home on December 31, 2021. 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the available records do not demonstrate ongoing clinical needs that could not be addressed at a lower level of care.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. Our physician reviewer found that your condition does not meet Medicare criteria for continued LTACH services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care after January 18, 2022.  You asked the Plan to pre-approve the continuation of inpatient psychiatric care. You say that this care continues to be medically necessary. The Plan denied your request. The Plan says inpatient mental health care is no longer medically reasonable and 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 the continuation of inpatient psychiatric care. Our reviewer says that the continuation of inpatient psychiatric care is not medically reasonable and necessary. Our physician reviewer found that based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 19, 2022, forward. This patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This patient was not showing any aggressive behaviors or any treatment required for acute threats of safety as she awaited placement. The requested care is no longer medically reasonable and necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care after January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve therapeutic facet joint injection procedure.  You asked the Plan to pre-approve facet join injection services. You say that this procedure is medically necessary for your pain. The Plan denied your request. The Plan says the criteria for coverage have not been satisfied for the requested procedure.  The Plan must follow Medicare rules. Medicare rules say that in order for therapeutic facet joint injections to be covered, there must be sufficient documentation as to why the enrollee is not a candidate for radiofrequency ablation.   We looked at the file and Medicare rules. In this case, no documentation has been presented as to why radiofrequency ablation would not be appropriate for your medical condition. Based on this information, we decided that Medicare rules for coverage of facet join injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic facet joint injection procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the autologous blood or component processing and storage (86891), special pump services (99190, 99191) and washed red blood cells (P9022) provided on June 1, 2021.  You asked the Plan to pay for the autologous blood or component processing and storage, special pump services and washed red blood cells.. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for these services is included in the payment to the facility.  The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the autologous blood or component processing and storage, special pump services and washed red blood cells. have not been met. Specifically, the record indicates that the member was a hospital inpatient on the billed date of service. Payment for these services is included into the payment for the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the autologous blood or component processing and storage (86891), special pump services (99190, 99191) and washed red blood cells (P9022) provided on June 1, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for inpatient hospital services provided on September 25, 2020, through October 2, 2020 and billed with Diagnosis Related Group code 205.  You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration because the medical records support the diagnosis code billed. The Plan denied your request. The Plan says that the documentation submitted does not support the secondary diagnosis code.  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. the Plan has not forwarded medical records relating to the services at issue. Of note, the file clearly indicates that the Plan reviewed medical records to support their denial. We are unable to verify if Medicare criteria for coverage has been met without medical records. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for inpatient hospital services provided on September 25, 2020, through October 2, 2020 and billed with Diagnosis Related Group code 205.   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.