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

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH care. The Plan denied your request. The Plan says the enrollee is medically stable and does not require close physician oversight and the use of specialized equipment or therapy. The Plan says that the enrollee does not meet the medical necessity guidelines for an LTACH admission.  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 enrollee was admitted with encephalopathy due to pneumonia and endocarditis in the setting of acute kidney failure. The record indicates that the enrollee is improving. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve twelve (12) additional physical therapy (PT) visits.  You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not meet criteria.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had prior therapy. The enrollee's deficits do not require the ongoing supervision of a skilled therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. The enrollee has been instructed in a home exercise program.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional physical therapy (PT) visits.
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.  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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to an inpatient rehabilitation facility (IRF) on February 1, 2022 for intensive therapy after hospitalization for a stroke. You have tolerated inpatient rehab services and continues to improve with daily skilled nursing and/or skilled therapy services. You have made slow progress with therapy and there is no indication that transfer to a SNF is required. There are no services offered at the SNF that are not available at the current IRF. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve HH PT visits (CPT code G0151 x8), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee's records suggest that continuing this exercise program should help them maintain their level of function or improve further. The Plan states the enrollee's records do not support the need for a skilled physical therapist to make more home visits at this time.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 services. Our physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented, ongoing, skilled PT needs. The enrollee is functioning at a level commiserate with a lower level of care (i.e. HEP, outpatient therapy). As such, the requested, ongoing, HH PT is not medically necessary or reasonable.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve HH PT visits (CPT code G0151 x8), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the parathyroid imaging services provided on September 29, 2021.  You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  The file shows that CPT code 78072 was billed with code 70492. We find that CPT code 78072 may be eligible for payment when billed with this code pair. However, the claim does not show that the CPT code 78072 was billed with a modifier suitable for payment. 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 parathyroid imaging services provided on September 29, 2021.
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 the enrollee was approved for a spinal cord stimulator trial 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 admission are met in this case. Our physician reviewer found the enrollee is approved for a spinal cord stimulator trial. 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 intraoral periapical first radiographic images (D0220 and D0230), provided on July 8, 2021.  You asked the Plan to pay for the intraoral periapical first radiographic images. You say that the services should be covered. The Plan denied your request. The Plan says these are not covered services.  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 intraoral periapical first radiographic images (D0220 and D0230), provided on July 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.  You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee requires additional transportation trips. The Plan denied your request. The Plan says that the enrollee's benefit for transportation is exhausted.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of twelve (12) trips per year.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips 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 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 need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing 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 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve 200 units of Botox. 
 
You asked the Plan to pre-approve 200 units of Botox. You say that this medication must be ordered in 100 
unit intervals. The Plan denied your request. The Plan says that the enrollee's dose is only 135 units. 
 
The Plan must follow Medicare rules. Medicare rules say that the program provides payment for the amount of 
drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as 
indicated on the vial or package label. 
 
We looked at the file and Medicare rules. The medication at issue must be ordered in 100 unit intervals. Based 
on this information, we decided that Medicare rules for coverage of 200 units of Botox have been met. 
Therefore, we decided that the Plan has to pre-approve 200 units of Botox.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the 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 need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility when stable medically.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.

You asked the Plan to pre-approve RFA services. You say that this procedure is medically necessary for your condition. The Plan denied your request. The Plan says the guidelines only allow 2 procedures a year and this limit has been met.

The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months.

We looked at the file and Medicare rules. In this case, the requested RFA services were requested in November 2021. At that time, you had exhausted the benefit limit for RFA services in the requested spinal region. Based on this information, we decided that Medicare rules for coverage of RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns - porcelain/ceramic (D2740) for teeth 8-9 and 22-28.

You asked the Plan to pre-approve crowns. You say that you would like these crowns covered. The Plan denied your request. The Plan says documentation provided demonstrates 50% or more bone loss and a poor crown to root ratio resulting in a poor long-term prognosis for these teeth.

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 crowns only for permanent teeth needing multi-surface restorations where other restorative materials have a poor prognosis. Permanent bicuspid teeth must have pathologic destruction to the tooth by caries or trauma and should involve three or more surfaces and at least one cusp. Permanent anterior teeth must have pathologic destruction to the tooth by caries or trauma and must involve four or more surfaces and at least 50% of the incisal edge. Criteria for crowns will not be met if the tooth has advanced periodontal disease or a lesser means of restoration is possible.

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 crowns. Our reviewer says that each of the teeth under consideration has multi-surface existing restorations that comprise about 35% of the tooth structure, but no incisal or cuspal involvement. Also, teeth #8, 9, 22 ,23, 24, 25, 26, 27 and 28 all show significant bone loss, in the vicinity of at least 50% - 70%. This constitutes severe periodontal disease, and makes the abutment teeth unsuitable for crowns, with crown to root ratios below 1:1 making for a poor long-term prognosis of the teeth. Given the lack of structural damage to the teeth that does not involve the incisal edges of the anterior teeth or the cusps of the posterior teeth, as well as the severe periodontal involvement of the teeth in question, the criteria for crowns under the Plan has not been met. The long-term periodontal prognosis is questionable to poor, and the teeth can be reasonably restored with conventional composite materials.

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 crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns - porcelain/ceramic (D2740) for teeth 8-9 and 22-28.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copay for the eye exam provided on October 20, 2021.

You asked the Plan to reduce the copay for the eye exam. You say that you shouldn't have to pay the bill. The Plan denied your request. The Plan says a medical eye exam was rendered.

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 $45 copay for services to diagnosis and treat a disease or condition of the eye. 

The file shows that you received a comprehensive medical eye exam, and not a routine eye exam on the date of service at issue. You have been asked to pay a $45 copay for the eye exam. The exam falls within the vision care 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 reduce the copay for the eye exam provided on October 20, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity study (93971) provided on September 18, 2021.

You asked the Plan to pay for the extremity study. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 93970 and 93971.

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 93971 is a column II code to column I code 93970. This claim has not been billed with an appropriate modifier to bypass the edit. 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 extremity study (93971) provided on September 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy service provided on October 19, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the chemotherapy service. You say that a pre-authorization was obtained from the Plan. The Plan denied your request. The Plan says the referring physician and the provider are non-participating providers with no prior authorization approved for this service.

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 chemotherapy service provided on October 19, 2021, by an out-of-network (OON) provider.