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

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states your request does not show you have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. The Plan states the services you require can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening prostate specific antigen (PSA) test coded with
procedure code G0103, received on May 10, 2021.
You asked the Plan to pay for the PSA test. You say that you thought this was a regular blood test, not a PSA
test. You do not recall when the last PSA test was done. The Plan denied your request. The Plan says the
enrollee was not eligible for another PSA test on this date. The enrollee received a covered PSA test on
September 16, 2020, so twelve months had not passed since the prior test. The Plan follows Medicare rules. Medicare rules say that PSA tests are only covered once per year. The
enrollee received a covered PSA test on September 16, 2020. The PSA test he received on May 10, 2021, was
less than twelve months since his last one. Based on this information, we decided that Medicare rules for
coverage of the PSA test have not been met. Therefore, we decided that the Plan does not have to pay for the
screening prostate specific antigen (PSA) test coded with procedure code G0103, received on May 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you require assistance. The Plan denied your request. The Plan says your request does not show you have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. The Plan states the services you require can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor. he 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast cancer diagnostic testing.
You asked the Plan to pre-approve the testing. You say that you cannot afford to pay for this out of pocket. The Plan denied your request. The Plan says this request does not meet the requirements for approval. 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, breast cancer testing, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes without a personal history of cancer. Therefore, we decided that the Plan does not have to pre-approve breast cancer diagnostic testing.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the magnetic resonance imaging (MRI) provided on July 21, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the testing does not meet coverage criteria.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the services provided by a contract provider. The file does not show that the Plan provided notice that the testing services would not be covered. Under Medicare rules, this means the services provided is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the magnetic resonance imaging (MRI) provided on July 21, 2021. 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 IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you need the rehabilitation to get back to your normal self. You state you cannot walk and need the rehabilitation to get back to doing your activities of daily living (ADL's) safely. The Plan denied your request. The Plan says you clearly require physical and occupational therapy as well as pain control with medicine by mouth and management of the medicines you routinely take every day by mouth. The Plan states you do not need to be seen by a rehabilitation doctor at least three (3) times a week for evaluation of functional and medical goals and progress and you do not need an intensive team (rehabilitation doctor and nurse, social worker, and therapists) for your care. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility.

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 upon your current level of function, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. IRF admission is not medically necessary. Document does not support the necessity. While you may benefit from physical therapy (PT), and occupational therapy (OT), your rehabilitation needs can be safely met in an alternate and low 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14-Day Sensor Kit, for the enrollee.
You asked the Plan to pre-approve the item. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin three or more times per day or is using an insulin pump, and the insulin dosing requires frequent adjustment. Based on this information, we decided that Medicare rules for coverage of the item have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14-Day Sensor Kit, for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of
the brain you had on June 30, 2021.
You asked the Plan to waive the copayment for the MRI. You say that this service was ordered to confirm a
diagnosis and was needed for a referral to a specialist. You believe the Plan should have paid its share for this
service. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says
that because the allowed amount for this service ($126.33) is less than your copayment obligation, you are
responsible for the full allowed 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 $160
copayment for radiological diagnostic services.You have been asked to pay a $160 copayment for the MRI. The MRI falls within the radiological diagnostic
services 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 magnetic resonance
imaging (MRI) of the brain you had on June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray of the cervical spine (72040) provided on April 22, 2021, by an out-of-network provider.
You asked the Plan to pay for an X-ray of the cervical spine. You say that the requested service was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 an X-ray of the cervical spine (72040) provided on April 22, 2021, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy with biopsy (45380) rendered on June 4, 2021.

You asked the Plan to waive the copayment for a colonoscopy with biopsy. You say that you were not informed of the extra charges and received a bill for $290. The Plan denied your request. The Plan says you were charged 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 $290 copayment for each Medicare covered outpatient hospital facility visit. 

You have been asked to pay a $290 copayment for a colonoscopy with biopsy. A colonoscopy with biopsy falls within the Outpatient Surgery 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 a colonoscopy with biopsy (45380) rendered on June 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 skilled nursing facility services. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical
records provided daily skilled services are not required. The enrollee's needs can be met in an alternate 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 skilled nursing facility services have not been met. Therefore, we decided
that the Plan does not have to pre-approve skilled nursing facility services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visit (CPT code G0299 X 4), 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 services are not necessary.
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. physician reviewer found the documentation does not support that the enrollee requires additional skilled nursing services to provide treatment that is medically necessary. The enrollee does not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not medically 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 home health skilled nursing visit (CPT code G0299 X 4), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant placement (D6010) for teeth # 3 and 4 provided on May 11, 2021.
You asked the Plan to pay for the dental services. You say that your coverage allows for "procedure for emergency treatment of dental pain, covered for an urgent or emergent visit only." You also say that this should be covered. The Plan denied your request. The Plan says implant placement is not listed as a covered service.
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 implant placements are not among those covered under this benefit. Additionally, the services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the implant placement (D6010) for teeth # 3 and 4 provided on May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care services provided on August 11, 2021.

You asked the Plan to waive the copayment for the wound care services. You say that you saw the provider at his office and not at the hospital. You say you only had your wound cleaned and dressed. The Plan denied your request. The Plan says you have been charged 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 $250 copayment for each visit for outpatient surgery. 

The wound care you received is considered a surgical service. The records confirm you received these services at an outpatient facility. You have been asked to pay a $250 copayment for the wound care services. The wound care services fall 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 the wound care services provided on August 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 11, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 15002, 15003, and 15004 are not supported.
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 15002 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children. The definition of code 15003 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to
code for primary procedure). The definition of code 15004 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children. We find that CPT codes 15002, 15003, and 15004 are not supported in the medical record. Specifically, there is no documentation of surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar, or incisional release of scar contracture of trunk, arms, or legs; first 100 sq cm or 1% of body area of infants and children, to support code 15002. Given that primary procedure code 15002 is not supported, add-on code 15003 is also not supported. There is no documentation of surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar, or incisional release of scar contracture of the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children to support code 15004.
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 pay for the surgical services rendered on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010).
You asked the Plan to pre-approve the sleeve. You say that the enrollee has lymphedema due to lymph nodes being removed on the right side as a result of breast cancer. The Plan denied your request. The Plan says the requested item is not covered.
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve is not covered. The requested item is statutorily non-covered. Based on this information, we decided that Medicare rules for coverage of the sleeve have not been met. Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010).