Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 9 one-hour skilled nursing visits.  You asked the Plan to pre-approve 9 one-hour skilled nursing visits. You say that the skilled nursing visits are medically necessary. The Plan denied your request. The Plan says the enrollee does not require skilled nursing care.  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 9 one-hour skilled nursing visits. Our reviewer says that 9 one-hour skilled nursing visits are not medically necessary. Our physician reviewer found the documentation does not support that you require additional skilled nursing services to provide treatment that is medically necessary. The reviewer found that you do not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. The reviewer found that you have been medically stable without any recent exacerbation of chronic medical problems or hospitalizations. Therefore, the reviewer found that the requested home health services are not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 9 one-hour skilled nursing visits have not been met. Specifically, the file does not indicate that you require skilled nursing care. Therefore, we decided that the Plan does not have to pre-approve 9 one-hour skilled nursing visits.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need 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 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for wound dehiscence of right mastectomy site after recent bilateral mastectomy and sentinel node biopsy for invasive carcinoma of the breast. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998), provided on January 22, 2021.  You asked the Plan to pay for the ambulance service. You say that the enrollee fell. You say that she did not require transport to the emergency room because she was back to "normal" by the time an assessment was completed. You also say that the enrollee was unvaccinated at the time, and it would not have been safe for them to go to the hospital. The Plan denied your request. The Plan says there was no transport provided. The Plan also says that since no transport was provided, there is no payable service.    The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on January 22, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998), provided on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair.  You asked the Plan to pre-approve a group 3 power wheelchair. You say that the records provided support the need for the requested group 3 power wheelchair. 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 a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:  1. A neurological condition;  2. Myopathy; or  3. Congenital skeletal deformity.  The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair.
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 the patient is able to tolerate 3 hours/day of therapies. The Plan denied your request. The Plan says that the enrollee can safely receive the services he needs 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 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. 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 pneumonia caused by influenza and atrial fibrillation with rapid ventricular response. The enrollee's medical problems are stable. 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 patient has a need for physical and/or occupational therapy, there is no documentation of 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 pre-approve a neurosurgery second opinion visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve specialist visit. You say that you will have surgery and need to be assisted by this specialist as soon as possible. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network neurosurgery specialist.  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 a neurosurgery second opinion visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown and core buildup provided by an out-of-network provider on June 8, 2021.  You asked the Plan to pay for the crown and core buildup. You say that you knew the dental office was not in -network with this Plan but you used your other insurance. You say that the Plan was able to get you an in-network dentist. The Plan denied your request. The Plan says you are responsible for the full cost of services obtained out-of-network.  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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown and core buildup provided by an out-of-network provider on June 8, 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 records provided support the need for IRF care. The Plan denied your request. The Plan says the medical necessity for admission to an IRF is not met. The Plan says that the enrollee's medical conditions present on admission are not yet stable.  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 it is not clear that the enrollee is medically stable for discharge due to reported increased confusion, lethargy, hypokalemia with a potassium of 2.8 on December 6, 2021, and the need for a ureteral stent placement for the stone with hydronephrosis.  The enrollee does require physical therapy and occupational therapy services but based on the medical records provided it is not clear that the enrollee is medically stable for discharge.  There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to her ongoing medical issues including increased confusion, lethargy, hypokalemia and the ureteral stent and hydronephrosis.   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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for a colonoscopy provided on May 20, 2021.  You asked the Plan to pay for the colonoscopy. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.  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 services 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 a colonoscopy provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sacroiliac joint injection services.  You asked the Plan to pre-approve sacroiliac joint injection services. You say that the records provided support the need for the requested injection services. The Plan denied your request. The Plan says the medical necessity criteria have not been met, as the enrollee does not have pain relief greater than or equal to 75% from the previous injections.  The Plan follows Medicare rules. Medicare rules say that the therapeutic frequency must remain at least two months or longer between pain management injections.  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 sacroiliac joint injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record indicates the enrollee underwent sacroiliac injection in November 2021. Two months have not passed since the previous injection and the degree of benefit is not documented.      We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injection services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a bone replacement graft (D7953), a tooth extraction (D7210), three (3) retainer crowns (D6740), three (3) core buildups (D2950) and a fixed partial denture pontic (D6245) provided on May 12, 2021, to June 14, 2021, by an OON provider.  You asked the Plan to pay for dental services. You say that services were only rendered after the provider contacted the Plan and confirmed an in-network contract status. The Plan denied your request. The Plan says services were obtained from a provider outside the vendors' network.  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 obtained from a provider in the Plan's dental vendor network.   We looked at the file and Medicare rules. The Plan has confirmed they did not have any phone calls on file where they advised you or the provider that this provider was in-network with your Plan. Specifically, the services were rendered by an OON provider. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a bone replacement graft (D7953), a tooth extraction (D7210), three (3) retainer crowns (D6740), three (3) core buildups (D2950) and a fixed partial denture pontic (D6245) provided on May 12, 2021, to June 14, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite (D2335) provided on April 27, 2021.  You asked the Plan to pay for the resin-based composite (D2335). You say that you visited this office to have the damaged tooth repaired. You say that this was on an emergency basis and you should be refunded. 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 pay for the resin-based composite (D2335) provided on April 27, 2021.    Your complaint about the insurance company being incompetent is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services provided on June 21, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.    The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes place.   We looked at the file and Medicare rules. The records show that the enrollee was under inpatient status when the anesthesia services were provided. This means that it is inappropriate to bill these services with an outpatient place of service code (22). 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 pay for the anesthesia services provided on June 21, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for the services (93042) provided on May 7, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this code is not payable.  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 argues that code 93042 is part of an edit pair with code 99291. However, an NCCI code pair search does not show that an edit exists between code 93042 and code 99291. This means that code 93042 is separately payable in this case. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (93042) provided on May 7, 2021.   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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998), provided on June 29, 2021.  You asked the Plan to pay for the ambulance service. You say that you called your medical alert service for a paramedic. You say that the paramedics did not feel you needed to go to the hospital. You say that if you had been taken to the hospital you only would have had a copayment. You also say that you feel the $305 charge is unfair. The Plan denied your request. The Plan says there was no transport provided. The Plan says that since no transport was provided, there is no payable service.    The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on June 29, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998), provided on June 29, 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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.