Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sixteen (16) additional physical therapy (PT) visits.
You asked the Plan to pre-approve sixteen (16) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
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 sixteen (16) 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by 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, 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sixteen (16) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve sixteen (16) additional PT visits
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that the enrollee is a fall risk and failed outpatient therapy. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or therapy services on an inpatient basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that the enrollee is at a supervision assist level for sit-to-stand and transfers. She is ambulating with contact guard assist using a rolling walker. The enrollee does not need skilled therapies on a daily basis in an inpatient setting with the above functional status. She is medically stable after recent Hyponatremia and an acute kidney injury. Both issues are resolved, and no daily skilled nursing care is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve insertion of a permanent cardiac contractility modulation system.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that until additional studies with long-term clinical outcomes are published, this request cannot be approved.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found cardiac contractility modulation therapy with the Optimizer device is a relatively newer technology which is FDA approved, but has limited randomized data showing modest benefit with regard to quality of life and walk time scores in patients already on maximal medical therapy. A recent randomized clinical trial (160 patients) who were also already on optimal guideline directed medical therapy for congestive heart failure, showed improvement in peak VO2, improved exercise tolerance on six minute walk, quality of life scores and re-hospitalization. These improvements seen were more prominently in study patients with mid-range left ventricular ejection fraction (LVEF) reductions (more than 35%). You remain with New York Heart Association (NYHA) Class III symptoms while on maximally tolerated therapy. In addition, your ejection fraction is in the 35% range which, based on the current trials, would be more likely to respond to this therapy. Your QRS is not prolonged and he would not be a candidate for cardiac resynchronization therapy (CRT) therapy either. Given these limitations, the persistent moderately severe Class III symptoms and the fact that he is still quite symptomatic on guideline directed therapy with no other clinical alternatives, based on both the published data and recent expert opinion as well as the approved FDA indications, you would therefore meet CMS criteria for medical reasonableness and necessity of this device based on the applicable CMS Section 1862(a)1(A) criteria. 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 procedure have been met. Therefore, we decided that the Plan has to pre-approve insertion of a permanent cardiac contractility modulation system.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share applied to the deductible for several physician services provided on April 19, 2021.
You asked the Plan to waive this cost share. You say that you do not believe these charges are correct. The Plan denied your request. The Plan says the charges were applied to the deductible per your Plan contract agreement. The Plan reviewed the medical records received from your physician's office, which state that you were seen for gastroesophageal reflux disease, in addition to your annual wellness exam. The medical records also show that you received an electrocardiogram, lab work, and were administered a pneumococcal vaccine. Per your 2021 Evidence of Coverage (EOC), Chapter 4, Page 52, under Annual wellness visit, it states that until you meet your yearly deductible, you pay up to 100% of the Medicare-approved amount or network contracted rate. On pages 60 and 61 of your EOC, under immunizations, it states that until you meet your yearly deductible, you pay up to 100% of the Medicare-approved amount or network contracted rate. The Plan states page 70 of the contract, under outpatient diagnostic tests and therapeutic services and supplies, it states that until you meet your yearly deductible, you pay up to 100% of the Medicare-approved amount or network contracted rate. On page 75, of the contract , under Physician/Practitioner services, including doctor's office visits, it states that until you meet your yearly deductible, you pay up to 100% of the Medicare-approved amount or network contracted rate.
Based on the claim submitted by your provider, the Medicare allowed amounts for the services you received were $137.12 for the annual wellness visit, $89.99, for the problem visit, $20.86, for the ECG, $21.00, for the vaccine administration, $241.38, for the Pneumococcal vaccine, and $2.40, for the venipuncture totaling the amount due of $512.75. Based on the Plan contract, you are responsible for 100% of the charges as you have not met your yearly deductible of $9,000.
The Plan is correct in this case. 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 deductible prior to services being covered by 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 cost share applied to the deductible for several physician services provided on April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for an onlay (D2643) provided on February 23, 2021.
You asked the Plan to pay an additional amount for an onlay. You say that the service was necessary, and you could not wait to be seen by an in-network provider. The Plan denied your request. The Plan says the claim for this service was processed correctly with the applicable out-of-network allowable amount paid.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an onlay have not been met. Specifically, the allowed amount of this service for an out-of-network provider was paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for an onlay (D2643) provided on February 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional PT visits.
You asked the Plan to pre-approve eight (8) additional PT visits. You say that the enrollee's progress was slow, and she required skilled physical therapy throughout that time to ensure proper form with exercises, appropriately progress exercise intensity, and ensure patient safely through clinical decision making. The Plan denied your request. The Plan says additional PT is not medically necessary.
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 eight (8) 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in safety precautions and a home exercise program. 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eight (8) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided out of network on March 31, 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 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 physician services provided out of network on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from April 7, 2021, to May 21, 2021.
You asked the Plan to pay for these services. You say that you thought you needed hip replacement but the work they did with the shoulder and the hip helped you. The Plan denied your request. The Plan says the services provided are not related to manual manipulation of the spine and therefore are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from April 7, 2021, to May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the 20% coinsurance ($608.88) charged for outpatient services provided on March 17, 2021.
You asked the Plan to waive or reduce this coinsurance. You say that you do not believe this coinsurance is correct. The Plan denied your request. The Plan says according to the 2021 Evidence of Coverage (EOC), you are responsible for a 20% coinsurance for radiology, diagnostic, and surgery services when rendered at a participating outpatient hospital. The Medicare allowed amount for this service is $3044.42 and 20% of that is $608.88.
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 20% coinsurance for outpatient surgical services.
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 or reduce the 20% coinsurance ($608.88) charged for outpatient services provided on March 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there are no noted skilled nursing or therapy needs on a daily basis as an inpatient.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that you are medically stable after recent cellulitis and sepsis. There are no daily skilled nursing care needs. You are at a moderate assist level for bed mobility, transfers, and walking. You do not need skilled therapies on a daily basis in an inpatient setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cooled left lumbar spine radiofrequency ablation (RFA) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found non-thermal RFA modalities, including chemical, low grade thermal energy, as well as pulsed RFA are not covered by Medicare. Therefore, the request is deemed not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve cooled left lumbar spine radiofrequency ablation (RFA) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 25, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every year.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on March 23, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 25, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital care and the emergency care provided from February 13, 2021, through February 16, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.

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 $250 copayment per day, for days 1-7 per inpatient hospital admission. Additionally, you must pay a $90 copayment for emergency care per visit.

You have been asked to pay $840 which includes a $250 copayment x 3 days for the inpatient hospital care provided. Additionally, this amount includes a $90 copayment for the emergency care provided. 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 copayments for the inpatient hospital care and the emergency care provided from February 13, 2021, through February 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for urography, retrograde (74420) provided February 8, 2021.
You asked the Plan to pay for the radiology services. You say that please reprocess for the appropriate billed amount as submitted on the claim for processing. The Plan denied your request. The Plan says procedure exceeds the maximum number of services allowed for a single date of 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. Medicare rules say that providers must report the actual number of units provided for each procedure code.
We find 2 units of CPT code 74420-26 are not supported in the medical record. The medical record only
supports 1 unit of CPT code 74420-26. The plan had paid for these services on February 8, 2021. Based on this
information, we decided that Medicare rules for coverage of the radiology servicers have not been met.
Therefore, we decided that the Plan does not have to pay for urography, retrograde (74420) provided February
8, 2021