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

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided 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. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically necessary.  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 based on the documentation provided, the health Plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. skilled nursing facility/sub-acute rehabilitation).  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 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 LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.  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 the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current 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 12 additional physical therapy visits (G0151).  You asked the Plan to pre-approve physical therapy services. You say that these services are medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage 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 physical therapy services. Our reviewer says that the requested home health physical therapy services are not medically reasonable and necessary. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The patient has been instructed on safety measures, an emergency plan, fall precautions, etc. Patient verbalized and demonstrated understanding of a home exercise program. Patient verbalized and demonstrated safe transfers and gait. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits (G0151).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional days in the skilled nursing facility.  You asked the Plan to pre-approve the additional days in the skilled nursing facility. You say that you do not have assistance at home and have a broken leg. You also say that you find it unacceptable that you still need skilled nursing care and are being discharged due to the 100-day benefit. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.   The file shows that you received 100 days of SNF care during the benefit period from July 25, 2021, to November 23, 2021. The Plan has covered 100 days of SNF care.  Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve additional days in the skilled nursing facility.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (G0483) provided on February 2, 2021.  You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS.  The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the claim was billed with the laboratory POS code while the record indicates that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on February 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 you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct.  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 continue to require critical care services which have not been denied. The records do not indicate that you require services that you are not currently receiving but that would be available at the LTACH.  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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the pontics (D6245) and retainer crowns (D6740 and D6750) for a fixed bridge.  You asked the Plan to pre-approve the pontics (D6245) and retainer crowns (D6740 and D6750). You say that you are having pain while eating and having trouble sleeping due to the pain. You say that you were given the option of a crown or bridge and are requesting a bridge for the dental issue. 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 pre-approve the pontics (D6245) and retainer crowns (D6740 and D6750) for a fixed bridge.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an evaluation to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the submitted records show that the most recent diagnostic medial branch block was not successful.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was not 80% pain relief from the diagnostic medial branch blocks, as required by the criteria. Therefore, the request is deemed not medically reasonable or 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 radiofrequency ablation for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF 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 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 the beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 skilled nursing facility (SNF) care.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.  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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for bilateral heel wounds and osteomyelitis in the setting of end-stage renal disease. The enrollee is not intubated or ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such time no acute services are required.  The enrollee can then be transferred or discharged to a lower level of care for any ongoing long term care needs.  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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the combination sit-to-stand frame/table system (E0637).  You asked the Plan to pre-approve the combination sit-to-stand frame/table system. You say that the item is medically necessary. The Plan denied your request. The Plan says your records show you do not require a patient lift to avoid being bedbound and this requested item has a tray/table feature that is not primary medical in nature.  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 the combination sit-to-stand frame/table system (E0637).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided on May 3, 2021.  You asked the Plan to pay for these services. You say that you were told these services would be covered. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.  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 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 out of network physician services provided on May 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure.  You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home health services provided to the enrollee on March 1, 2021 billed under code G0299.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says code G0299 has a status indicator of "X", meaning this code is not in the statutory definition of physician services on the fee schedule for payment purposes. Home health services must be reported appropriately with a corresponding revenue code.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes.  In this case, this claim cannot be paid as billed due to the omission of the appropriate revenue code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on March 1, 2021 billed under code G0299.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a rebase of a maxillary partial denture (D5720).  You asked the Plan to pre-approve the rebase of a maxillary partial denture. You say that the enrollee presented for an exam and the x-ray and clinical exam revealed a broken tooth #8. You also say that you advised the best prognosis would be adding tooth #8 to the existing partial. The Plan denied your request. The Plan says denture relines and adjustments are included with the denture benefit when performed within six months of the denture placement.  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, rebase maxillary partial denture (D5720) is not covered within 6 months of initial placement. The record shows that the enrollee received a maxillary partial denture (D5211) on June 9, 2021. The Plan says that adjustments made within the first 6 months of receiving the denture are included with the cost of the denture. If this procedure is rendered within 6 months of June 9, 2021, you will not need to send a bill for this service. Therefore, we decided that the Plan does not have to pre-approve a rebase of a maxillary partial denture (D5720).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) machine purchased on July 14, 2021.   You asked the Plan to pay for this equipment. The Plan denied your request. The Plan says this equipment is typically rented and not purchased. The Plan says that the provider in this case is not a Medicare eligible provider and you did not have prior authorization.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided by a vendor who is not a Medicare eligible provider. This equipment was purchased without prior authorization from a provider who is not eligible to bill Medicare or accept Plan or Medicare payment. Therefore, we decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) machine purchased on July 14, 2021 from CPAP.com.