Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician visits provided on June 17, 2021, to July 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for physician visits. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 physician visits provided on June 17, 2021, to July 22, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2740) for tooth # 13.

You asked the Plan to pre-approve a crown. You say that you need this crown. The Plan denied your request. The Plan says that a crown for tooth # 13 is not medically necessary.

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. The Plan covers a crown when the services are medically necessary and reasonable. 

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 crown. Our reviewer says that the requested crown for tooth # 13 is medically necessary. Our physician reviewer found the provided documentation indicates that a root canal and post/core has been approved for tooth # 13. As a result, a crown restoration is medically reasonable and necessary to provide adequate masticatory function. Therefore, the reviewer found that a crown for tooth # 13 is medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown have been met. Specifically, the file indicates that a crown will be necessary to provide adequate masticatory function once previously approved services are rendered. Therefore, we decided that the Plan has to pre-approve a crown (D2740) for tooth # 13.

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: 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 care can be provided safely at a less intensive setting 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 above.
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 a radical
nephrectomy and liposarcoma resection. The enrollee's medical conditions are stable. There are no medical
needs requiring inpatient admission. 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 medical record documents a need for physical and
occupational therapy, it does not document a need for an intensive 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit (Q5106).
You asked the Plan to pre-approve Retacrit. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Retacrit. Our reviewer says that the service is not medically necessary. Our physician reviewer found the requested use of Retacrit is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Specifically, this drug is not reasonable or necessary for the patients intended use. Therefore, we decided that the Plan does not have to pre-approve Retacrit (Q5106).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for intraoperative neurophysiology monitoring (G0453) provided on May 7, 2021.  You asked the Plan to pay for intraoperative neurophysiology monitoring. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.  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 G0453 is a column II code to column I code 95816. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for intraoperative neurophysiology monitoring (G0453) provided on May 7, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the selective catheter placement (36246) provided to the enrollee on May 15, 2019.
You asked the Plan to pay for these services. You say that the procedure was changed to better treat the enrollee. The Plan denied your request. The Plan says that that there was no prior authorization for these services.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided the Evidence of Coverage for the enrollee's 2019 Plan. Without this documentation we are unable to determine if the enrollee has an out of network benefit or if the enrollee does or does not meet out of network criteria. Therefore, we decided that the Plan has to pay for the selective catheter placement (36246) provided to the enrollee on May 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on August 11, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on August 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from December 11, 2020, through December 18, 2020, and billed with principal diagnosis code A41.9.  You asked the Plan to pay for the inpatient hospital care as billed. You say that the documentation supports the billed principal diagnosis code. The Plan denied your request. The Plan says the principal diagnosis code submitted is not supported in the medical documentation.  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 principal diagnosis, A41.9, defined as sepsis, unspecified organism. 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 the inpatient hospital care as billed. Our reviewer says that the documentation does not support the principal diagnosis code of A41.9, defined as sepsis, unspecified organism. Our physician reviewer found that the documentation available in the medical record for review supported and admission for rhabdomyolysis in a patient with a past medical history to include chronic obstructive pulmonary disease and hypertension. While the diagnosis of sepsis is documented on admission, throughout the progress notes and in the discharge summary, other medical record documentation regarding sepsis was incomplete. On physical exam, the documentation noted no acute distress, not ill or toxic-appearing with normal pulmonary effort, lungs clear to auscultation bilaterally, neurological status of alert. The History and Physical Examination documentation indicated the patient remained awake and oriented to person and place, without obvious distress with clear lungs and normal speech. Subsequent progress note documentation indicated acute kidney injury was likely secondary to rhabdomyolysis from falling as well as the underlying cause of the elevated liver enzymes. The patient was noted to actively participate in physical therapy sessions beginning on December 13, 2020. There was no documentation of sepsis. The review has determined that billed principal diagnosis code, A41.9 - Sepsis, unspecified organism, was not supported in the medical documentation.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from December 11, 2020, through December 18, 2020, and billed with principal diagnosis code A41.9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on October 27, 2021.  You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown. You say that the Plan approved the crowns for tooth #'s 10 and 11. You also says that the work started in 2020 and has never been completed. The Plan denied your request. The Plan says these implant service benefits have a limit to two in a calendar year. The Plan also says that your history plus this request have gone over these limits.  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, custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) are each limited to two per 1 calendar year. The record shows that you received custom fabricated abutments (D6057) on tooth #'s 5 and 12, and abutment supported porcelain/ceramic crowns (D6058) on tooth #'s 5 and 12 on September 2, 2021 and your custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) benefits had been exhausted. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on October 27, 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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require an IRF level of supervision. The enrollee has no evidence of significant pain, infection, or requires intensive monitoring of his medical condition in an IRF. While the enrollee may benefit and participate in multiple therapies, the enrollee's functional level does not require this on an 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on October 19, 2020, to November 16, 2020.  You asked the Plan to waive the copayment for physical therapy. You say that you were never consulted about the additional 12 sessions you needed. The Plan denied your request. The Plan says the correct copayments have been applied.  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 $40 copayment for outpatient rehabilitation services.   You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you are being asked to pay is $480 ($40 x 12 visits = $480). The correct copayments have been applied to the physical therapy services that were provided. Physical therapy falls within the outpatient rehabilitation 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 physical therapy provided by a participating provider on October 19, 2020, to November 16, 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 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 can safely receive the services needed in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 does 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 conditions are stable. There are no medical needs requiring
inpatient admission. 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 medical record documents a need for physical and occupational
therapy, it does not document a need for an intensive 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for pain management provided on July 21, 2021.  You asked the Plan to waive the copayment for pain management. You say that you received services from a physician's assistant, not a specialist. 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 a $35 copayment for pain management assessments.  The medical records show that you received pain management on July 21, 2021. Therefore, you are responsible to pay the $35 copayment.   You have been asked to pay a $35 copayment for pain management. Pain management falls within the outpatient diagnostic tests and therapeutic services and supplies 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 pain management provided on July 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for post cataract laser surgery (66821) provided on November 2, 2021.

You asked the Plan to waive the copayment for the post cataract laser surgery. You say that the services should be covered as you were not made aware of the copayment beforehand. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for Physician/Practitioner services, including doctor's office visits.

You have been asked to pay a $30 copayment for post cataract laser surgery. The Plan record indicates that there were no attempts to verify the cost-sharing with the plan. Post cataract laser surgeries fall within the Physician/Practitioner services, including doctor's office visits 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 post cataract laser surgery (66821) provided on November 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where 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.  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.