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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on February 8, 2020, to February 13, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that you would like these services authorized. You say that these services were medically necessary. The Plan denied your request. The Plan says this admission doesn't meet criteria for an inpatient hospitalization.

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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment were met in this case. Our physician reviewer found based on provided documentation, there were no expectations that the patient would require hospital services that would likely cross two midnights. Our doctor found that a lower level of care would have been more appropriate for ongoing treatment.

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 pay for the acute inpatient hospital care provided on February 8, 2020, to February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dialysis treatment services provided May 13, 2021 to June 29, 2021.

You asked the Plan to waive the copayment for the dialysis services. You say that the charges that were covered in years past show that all claims were covered in full. This co-insurance seems entirely out of line from the other copayments under the policy. The Plan denied your request. The Plan says this claim was processed with the correct cost share applied per the Evidence of Coverage.

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 dialysis. 

You have been asked to pay $1,131.15 ($452.46 + $678.69) 20% coinsurance for outpatient dialysis for the dialysis services. Dates of service 05/13/2021 -05/27/2021 had a coinsurance amount of $452.46. Dates of service 06/01/2021-06/29/21 had a coinsurance amount of $678.69. The dialysis services fall within the Services to treat kidney disease benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the dialysis treatment services provided May 13, 2021 to June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee, alignable
system (CPT code L5910) and addition, endoskeletal system, below knee, flexible protective outer surface
covering system (CPT code L5962).
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your
request. The Plan says the notes do not show why your current alignable system cannot be used with the new
socket. The Plan states the other part is an extra cover and the records do not show you would be using your
artificial leg in very harsh conditions, so that the approved custom shaped protective cover will not be enough.
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 items. Our physician reviewer
found there is no documentation that supports that your activity subjects you to harsh environmental situations
or that you engage in any extraordinary activities that would justify the need for extra protection with a flexible
outer surface covering system (L5962). Custom cover over is requested to protect internal components from
exposure due to environmental moisture and debris. Protection of prosthetic components can be achieved with
the L5704, Custom Shaped Protective Cover Below Knee that has been approved. The L5962 Addition,
Endoskeletal, Below Knee, Flexible Protective Outer Surface Covering is not medically necessary and cannot
be covered. The review has determined that the medical records provided do not meet the requirements listed in
the LCD for Medicare coverage.
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 items have not been met. Therefore, we decided that the Plan does not have
to pre-approve addition, endoskeletal system, below knee, alignable system (CPT code L5910) and addition,
endoskeletal system, below knee, flexible protective outer surface covering system (CPT code L5962).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be
provided at a lower level.
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 has a past medical history of
pulmonary fibrosis, atrial fibrillation, diabetes and a recent coronavirus infection managed at home who
remains at home with weakness despite home health physical therapy. 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound guided injection provided on
August 26, 2020.
You asked the Plan to waive the copayment for an injection. You say that you went for an injection, and you
are now being charged for outpatient surgery. The Plan denied your request. The Plan says you have been
asked to pay the correct cost sharing 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 a $350
copayment for outpatient procedures and services.
You have been asked to pay $306.82, which is less than the $350 copayment for an injection. An injection falls
within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory
Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound guided
injection provided on August 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be in an IRF, as it would be better than a skilled nursing facility (SNF) services. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could receive the care needed in another 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 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 was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 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 a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the 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: 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 care in an LTACH. The Plan denied your request. The Plan says LTACH care is not medically necessary. The Plan says that there are no required medical services in the LTACH that are not available in the approved hospital where the enrollee is.

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 indicating medical necessity for the requested LTACH services. 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 acute care hospital where she 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for neuro degenerative disease predisposition testing provided on October 1, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this screening test is not covered by Medicare.

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, genetic testing, is screening in nature. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for neuro degenerative disease predisposition testing provided on October 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided on
February 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because
the services provided were medically necessary and meet all applicable professionally recognized standards of
healthcare. The Plan denied your request. The Plan says there was no documentation of consultation with the
attending or primary care physician in the medical records.

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 the individual psychotherapy services (90834)
provided on February 19, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic and retainer crowns provided on March 30, 2021.
You asked the Plan to pay for the pontic and retainer crowns. You say that the dentist is an in-network provider and you were not aware the service was not covered. You say that you do not have the money to pay and being billed is unfair. The Plan denied your request. The Plan says the services are not covered benefits.
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 pontic and retainer crowns provided on March 30, 2021.
Your complaint about being scammed and cheated is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 transfer to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. 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.
Our physician reviewer found that 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. 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 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: 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 there is no documentation provided indicating medical necessity for the requested LTACH services. 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 acute care hospital where they are 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee meets the Medicare criteria for
coverage of SNF care. You say that the enrollee has sufficient medical and physical complexity supporting this
discharge plan. You say that the clinical documentation supports the need for SNF care. The Plan denied your
request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could
receive the care needed in another setting.
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 the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled
nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily
basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a
SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for additional units of an office visit (99203), nail trimming (G0127), lesion trimming (11056), and debridement (11720) provided on January 28, 2021.
You asked the Plan to pay for additional units of an office visit, nail trimming, lesion trimming, and debridement. You say that this is supported in the records. The Plan denied your request. The Plan says these services were previously billed and paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that additional units of CPT codes 99203, G0127, 11056, and 11720 are not supported in the medical record. The medical record only supports one unit each of CPT codes 99203, G0127, 11056, and 11720, which were previously billed and paid. Based on this information, we decided that Medicare rules for coverage of additional units of an office visit, nail trimming, lesion trimming, and debridement have not been met.
Therefore, we decided that the Plan does not have to pay for additional units of an office visit (99203), nail trimming (G0127), lesion trimming (11056), and debridement (11720) provided on January 28, 2021.