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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary The Plan denied your request. The Plan says that admission to an IRF was denied as not meeting IRF criteria, not medically necessary, and a lower level of care might be appropriate.

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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. 

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 massage services provided on March 25, 2021.

You asked the Plan to pay for massage services. You say that this is done on the same day for muscles that need to be repaired for strength and balance. You say that reimbursement should be processed. The Plan denied your request. The Plan says massage and wellness services are not a covered benefit under your Wellness Allowance.

The Plan must follow Medicare rules. Medicare does not cover massage therapy services and plans may not offer a massage therapy benefit. Therefore, we decided that the Plan does not have to pay for massage services provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the services you received on March 17, 2021.

You asked the Plan to waive the deductible. The Plan denied your request. The Plan says you are responsible for the deductible.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,300 deductible which you must pay out-of-pocket before the Plan will pay its share for your covered medical services. 

The requested service falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,300 deductible you must pay out-of-pocket before the Plan will pay its share for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time the services was received on March 17, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the services you received on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bitewing x-rays (D0272), an initial periapical x-ray (D0220), and an additional periapical x-ray (D0230).
You asked the Plan to pre-approve the dental services. You say that you received a bill for $57. You say that you knew you should not have received a bill as you are covered for routine cleanings and x-rays. You say that you were not advised that the services rendered would not be covered. You also say that you feel you should not be responsible for these services. The Plan denied your request. The Plan says bitewing x-rays and periapical x-rays are not listed as 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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bitewing x-rays (D0272), an initial periapical x-ray (D0220), and an additional periapical x-ray (D0230).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA).

You asked the Plan to pre-approve RFA procedure. You say that the enrollee continues to have pain and you are requesting to repeat the bilateral lumbar radiofrequency ablation. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has already exhausted the frequency limit of 2 sessions per spinal region within 12 rolling months.

The Plan follows Medicare rules. Medicare rules state that radiofrequency ablation may be covered under certain circumstances, but no more than 2 radiofrequency sessions will be covered per rolling 12 months.

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 RFA procedure. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested RFA procedure. Our physician reviewer found the enrollee has undergone RFA of the bilateral lumbar spine in November 2020 and RFA of the left lumbar spine in August 2021. Therefore, the enrollee has exhausted the covered 2 sessions per spinal region within 12 rolling months. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA).
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 these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's 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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for respiratory failure and COVID 19 pneumonia. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.

You asked the Plan to pre-approve a power wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records do not support medical necessity.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 a power wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal a personal mobility deficit that impairs participation in MRADLs. The documentation does not reveal that this deficit is unable to be helped by a walker, cane, or manual wheelchair, or that you can safely operate the wheelchair.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network (OON) provider.

You asked the Plan to pay for laboratory services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 laboratory services provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the information needed to allow this request was not received.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the requested level of service is L4-L5 and L5-S1. The record does not indicate that the enrollee has had at least two (2) medically reasonable and necessary diagnostic medial branch blocks, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain. The elements of the coverage criteria are not satisfied. 

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 radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the occlusal guard (D9940).

You asked the Plan to pre-approve the occlusal guard (D9940). You say that you almost go to the hospital because of the pain you are in. You say that the service is necessary, and the dentist says you need it. The Plan denied your request. The Plan says the service is not a covered benefit.

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 pre-approve the occlusal guard (D9940).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted special service coded 99199 provided on January 28, 2021.
You asked the Plan to pay for the unlisted special service. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99199 is unlisted special service, procedure or report. We find that CPT code 99199 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of unlisted special service, procedure or report; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the unlisted special service have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted special service coded 99199 provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on February 21, 2020.

You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the charges because you always pay every time you receive the injection. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 Medicare Part B prescription drugs. 

The medical records show that you received a Medicare Part B drug on February 21, 2020. The total allowed amount is $1,156.68 and 20% of that is $231.34. 

You have been asked to pay the total coinsurance amount of $231.34 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug provided on February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ambulatory infusion pump (E0781) infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) (A4222) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the infusion pump and supplies. You say that you were only going by what your doctor recommended for you to get the pump from. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the ambulatory infusion pump (E0781) infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) (A4222) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care provided from May 5, 2020, to May 9, 2020, and billed with DRG (diagnosis related group) 871.

You asked the Plan to pay for inpatient care. You say that the billed DRG is supported in the records. The Plan denied your request. The Plan says that DRG 193 is more appropriate.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 

In this case, you billed the inpatient services provided with DRG 871, septicemia or severe sepsis without mechanical ventilation greater than 96 hours with major complications or comorbidities. 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 pay for inpatient care. Our reviewer says that the documentation supports DRG 871. Our physician reviewer found the records show that the enrollee presented to the hospital with shortness of breath. At the time of admission, the enrollee was tachycardic and tachypneic. A computed tomography scan was notable for interval worsening in diffuse bilateral multifocal pulmonary opacities characteristic of worsening pneumonia. Laboratory studies were notable for leukocytosis, anemia, renal failure, and acidosis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient care provided from May 5, 2020, to May 9, 2020, and billed with DRG (diagnosis related group) 871.

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 pre-approve sacroiliac joint injections (27096).
You asked the Plan to pre-approve the injections. You say that the injections were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that therapeutic sacroiliac (SI) joint injections of an anesthetic and/or steroid to block the joint for immediate, and potentially long lasting, pain relief are considered medically reasonable and necessary if it is determined that the SI joint is the source of pain. 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 injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found confirmatory physical exam tests are not documented. The records do not show how the SI joint was determined to be the source of pain. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injections (27096).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80053, 81001, 85025, and 87086 provided on March 28, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 laboratory testing at issue in this appeal 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 coded 80053, 81001, 85025, and 87086 provided on March 28, 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 this is necessary for your recovery. The Plan denied your request. The Plan says you can be treated 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. Our physician reviewer found based on the records provided, you do not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the documentation does support a need for physical or occupational therapy, there is no documented need for a intensive, multi-disciplinary 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. 

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.