Persius/hicric huggingface dataset:
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 SNF care. You say that the enrollee does not meet the criteria for care in an
inpatient rehabilitation facility and will better gain treatment in a SNF. The Plan denied your request. The Plan
says the enrollee's needs can be met in the inpatient rehabilitation setting.
The Plan must follow Medicare rules. Medicare rules say that to consider coverage and payment for any item
or service, information must be submitted that corroborates the documentation in the beneficiary's medical
documentation and confirms that Medicare coverage criteria have been met
We looked at the file and Medicare rules. There were no medical records submitted to demonstrate that the
enrollee meets the criteria for coverage. The Plan has shown that they made reasonable attempts to obtain
medical records for review. Without this necessary information, we are not able to evaluate whether SNF care
is medically reasonable and necessary. 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 skilled
nursing facility (SNF) services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital services.

You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The Plan denied your request. The Plan says the inpatient level of care is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the inpatient level of care is not medically necessary. Our physician reviewer found the enrollee was approved for an elective total hip replacement. The records do not show that he will require at least two midnights of inpatient care for the procedure and post-operative care. The inpatient 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital 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 you are not able to walk more than 22 feet 
and is not safe for discharge. You say that the clinical information provided supports the need for SNF care. 
The Plan denied your request. The Plan says the enrollee does not require skilled nursing or therapy on a daily 
basis as an inpatient only status. The Plan says that the care needed can safely be received at a different 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 the enrollee received physical 
therapy and occupational therapy. The enrollee was an independent to supervision level with functional 
mobility, including gait to 30 feet with a rolling walker. The enrollee required varying assist with activities of 
daily living. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87101, 88305, 88311, 88312) rendered by the out-of-network (OON) provider on March 1, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (87101, 88305, 88311, 88312) rendered by the out-of-network (OON) provider on March 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on April 22, 2021, and the 
discharge day management provided on April 23, 2021. 
 
You asked the Plan to pay for the inpatient physician services. You say that the services are supported by the 
records provided. The Plan denied your request. The Plan says records did support two of the dates but did not 
include documentation for April 22 and April 23. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must submit information to corroborate 
that Medicare criteria are met. 

In this case, there are no records showing the services provided on April 22 and April 23, 2021. Therefore, we 
decided that the Plan does not have to pay for the critical care services provided on April 22, 2021, and the 
discharge day management provided on April 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab 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 skilled nursing facility. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her new baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab 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 admission to a skilled nursing facility (SNF).
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

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 you are receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that you require 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional home health skilled nursing visits.
You asked the Plan to pre-approve home health skilled nursing services. You say that this care is medically necessary. The Plan denied your request. The Plan says the criteria for additional home health skilled nursing services have not been met.
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 home health skilled nursing services. Our reviewer says that the requested care is not medically reasonable and necessary. Our physician reviewer found based on the medical records provided there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. Records provided do not document any unstable or new medical conditions requiring skilled nursing services beyond what has already been provided to the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional home health skilled nursing visits.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 you are receiving acute hospital care, and acute care services have not been denied. The documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve massage therapy. You say that you are in constant pain and believe massage
therapy will help. You say that you have done it before, and it did relieve some of the pain. The Plan denied
your request. The Plan says Medicare and the Plan do not cover massage therapy.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore,
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urology visit you had on May 27, 2021.

You asked the Plan to waive the copayment for the urology visit. You say that you don't believe you should have to pay this copayment. You said that you were scheduled for a prostate biopsy and when you went to the appointment, the doctor advised you that he doesn't perform this procedure for patients over 70 years old. You said that you were only in the office 2-3 minutes and the copayment should be waived because you should have been told this information before your visit. The Plan denied your request. The Plan says you were charged this copayment correctly

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for visits with a specialist. 

You have been asked to pay a $45 copayment for the urology visit. This copayment applies regardless of the reason for the visit or the length of the visit. 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 urology visit you had on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87634) provided to the enrollee on August 17, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied code remains 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, we have confirmed that code 87634 has a bundled relationship with code 87798 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87634) provided to the enrollee on August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve midnight blue accent color (K0108) for a power wheelchair.
You asked the Plan to pre-approve midnight blue accent color. You say that the requested color kit is a necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the request does not primarily serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve midnight blue accent color (K0108) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210) and consultation (D9310) to be provided by an oral surgeon.

You asked the Plan to pre-approve the surgical extraction and consultation. You say that you would like to appeal these services. The Plan denied your request. The Plan says dental services performed by an oral surgeon are not covered.

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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210) and consultation (D9310) to be provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Uvulopalatopharyngoplasty (UPPP).

You asked the Plan to pre-approve Uvulopalatopharyngoplasty (UPPP). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 Uvulopalatopharyngoplasty (UPPP). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee obstructive sleep apnea. A pulmonary note dated January 28, 2021 documents that the enrollee had the bilevel positive airway pressure (BiPAP) device for one year, and was doing well on BiPAP 13/9. The ears, nose and throat visit note dated August 5, 2021 documents that the enrollee had a polysomnogram which demonstrated significant sleep apnea. It is noted that the enrollee tried a continuous positive airway pressure (CPAP) machine multiple times and has been unable to use the machine effectively. The enrollee continued to have a great deal of daytime somnolence. The physical exam revealed +1 tonsils with hypertrophy.

The uvula was somewhat pendulous. UPPP is generally considered when BiPAP or an oral appliance have been ineffective. The documentation available in the case file is inconsistent regarding the effectiveness of BiPAP. Therefore, the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Uvulopalatopharyngoplasty (UPPP) have not been met. Therefore, we decided that the Plan does not have to pre-approve Uvulopalatopharyngoplasty (UPPP).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) and surgical extraction (D7210) to be provided by an oral surgeon.
You asked the Plan to pre-approve the bone replacement graft and surgical extraction. You say that the dentist you went to is in-network. The Plan denied your request. The Plan says dental services provided by an out-of-network provider or oral surgeon are not covered.
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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft (D4263) and surgical extraction (D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the fixed partial denture sectioning (D9120).
You asked the Plan to pre-approve the fixed partial denture sectioning (D9120). You say that you have a problem swallowing and you need the bridge to be repaired or to get a new bridge. You say that you are filing to get the tooth repaired with the bridge. 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 fixed partial denture sectioning (D9120).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT
code 22869), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is to treat the enrollee's lumbar spinal stenosis
with neurogenic claudication. The Plan denied your request. The Plan says unproven and not medically
necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

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 surgery. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis
with claudication. The record indicates that the enrollee has severe central spinal stenosis at L4-L5, the level
planned for treatment. The elements of the coverage criteria are not satisfied. The requested service cannot be
recommended.

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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22869), for the enrollee.