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

 We decided that the Plan does not have to pay for the telehealth outpatient visit provided on April 16, 2021, by an OON provider.  You asked the Plan to pay for the telehealth outpatient visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the telehealth outpatient visit provided on April 16, 2021, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval of SNF care. The Plan says that the enrollee's needs can be met at a lower level of care.  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 does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee is still receiving acute medical care with documentation of a plan for IV iron on December 8, 2021, and a referral plan to outside hospitals for hepatobiliary surgery. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF.  As a practical matter this enrollee does not require the necessary services on 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 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: 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 due to the complexity of the enrollee's case, the enrollee is too high level for a lower level of care but is stable enough to transfer to an LTACH for continued oxygen weaning. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to an LTACH.  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 that there is no documentation provided indicating medical necessity for 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 acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 you experience falls and exacerbation of your condition at home. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  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 do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the occlusal guard (D9944).  You asked the Plan to pre-approve the occlusal guard (D9944). You say that you need a new appliance that your general dentist is capable of fabricating for you. You say that you do not want the pain to return, you want to protect your teeth and it will cost less to approve this. 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 occlusal guard (D9944).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee requires inpatient rehabilitation services for management of complex, potentially life-endangering medical conditions and would highly benefit from a multidisciplinary team approach. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee may require physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for mobile imaging services rendered by an out of network provider on March 10, 2021.   You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you do not have prior authorization to receive services from an out of 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 mobile imaging services rendered by an out of network provider on March 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for an inpatient stay for a paraesophageal hernia repair and possible Collis gastroplasty.  You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says none of the requirements are met for an inpatient stay.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record indicates that the enrollee is scheduled for a paraesophageal hernia repair and possible Collis gastroplasty. The record indicates that the enrollee is medically stable and has received medical clearance for the planned procedure. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation. The elements of the coverage rule are not satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient stay for a paraesophageal hernia repair and possible Collis gastroplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for intravenous moderate sedation (D9239 and D9243) and removal of an impacted tooth (D7241) provided by an out-of-network.  You asked the Plan to pay for intravenous moderate sedation (D9239 and D9243) and removal of an impacted tooth. You say that these services were medically necessary. The Plan denied your request. The Plan says services must be provided by a participating provider.  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 intravenous moderate sedation (D9239 and D9243) and removal of an impacted tooth when the services are provided by participating providers.   We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of intravenous moderate sedation (D9239 and D9243) and removal of an impacted tooth have not been met due to services being provided by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for intravenous moderate sedation (D9239 and D9243) and removal of an impacted tooth (D7241) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a porcelain crown (D2740) provided by a participating provider.  You asked the Plan to pre-approve a porcelain crown (D2740). You say that this crown is needed to prevent breaking. The Plan denied your request. The Plan says this covered benefit has already been exhausted.  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 porcelain crown (D2740) once every five years per tooth.          We looked at the file and Medicare rules. Evidence was provided that show D2740 was provided on February 14, 2017. Based on this information, we decided that the Plan's rules for coverage of a porcelain crown (D2740) have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2740) provided by a participating provider.
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 enrollee meets the LTACH admission criteria, and her ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable discharge. The Plan denied your request. The Plan says the clinical information does not show that the guidelines for long term acute care services have been met. The Plan says that the enrollee can safely receive the care needed in the current hospital setting.  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 was admitted to the acute care hospital with hypoglycemia, hyperkalemia, complicated by acute respiratory failure, cardiac arrest, necrotic bowel requiring resection, septic shock, V-tach, GI bleed, and encephalopathy. Recent notes show the enrollee's mental status has not improved significantly but she is not combative anymore since starting Seroquel. She has completed antibiotics, is on trach collar, and vitals otherwise are improved and stable.  The enrollee appears to be improving and more stable requiring only short-term additional acute care services that can be safely administered at the current facility. The enrollee does not require LTACH services that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to LTACH will be considered not medically necessary as there would be no clinical advantage. Completion of care at the current facility is 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 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 pay for a continuous passive motion (CPM) device provided from April 26, 2021, to July 14, 2021.  You asked the Plan to pay for a CPM device for use after shoulder surgery. You say that a CPM device was necessary for use after shoulder surgery. The Plan denied your request. The Plan says Medicare does not cover this device for use after shoulder surgery.  The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. You used this device for treatment after shoulder surgery. This is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for a continuous passive motion (CPM) device provided from April 26, 2021, to July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the LifeVest you received on June 5, 2021.  You asked the Plan to waive the coinsurance for the LifeVest. You say that you do not agree with this cost sharing. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment.   You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical equipment 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 coinsurance for the LifeVest you received on June 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the facet joint radiofrequency ablation services.  You asked the Plan to pre-approve the facet joint radiofrequency ablation services. You say that these services have previously been beneficial for the enrollee's condition. The Plan denied your request. The Plan says based on Medicare coverage criteria, this service has been exhausted per rolling 12-month period.  The Plan must follow Medicare rules. Medicare rules say that no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months.  We looked at the file and Medicare rules. In this case, the record indicates that these services have been previously received in February 2021 and March 2021. Based on this information, we decided that Medicare rules for coverage of the facet joint radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve the facet joint radiofrequency ablation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient mental health care you received from June 25, 2021, to June 29, 2021.  You asked the Plan to waive the copayment for the inpatient mental health care. You say that you do not think you should have to pay anything for these services. 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 $295 copayment per day for days 1-4 for inpatient mental health care.   Records show that you received inpatient mental health care for 4 days.  You were charged a $295 copayment per day, for a total of $1180. This copayment applies regardless of your satisfaction with the services. 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 inpatient mental health care you received from June 25, 2021, to June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial lower denture (D5214).  You asked the Plan to pre-approve the dental item. You say that you do not have any teeth on the top or bottom. You also say that it is very difficult for you to eat. The Plan denied your request. The Plan says there is less than 50% bone support. The Plan also says that a partial lower denture does not meet the criteria for coverage.  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 dental services when the services are medically necessary and reasonable.  We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the partial denture have not been met. Specifically, the file did not include the necessary documentation to determine if the requested dental item was necessary. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary visit provided on May 12, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary visit. You say that the doctor should not be penalized for the hospital staffs' failure to obtain prior authorization. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on May 12, 2021, by an out-of-network (OON) provider.