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

We decided that the Plan does not have to pre-approve a continued inpatient psychiatric level of care beginning September 24, 2021 forward.
You asked the Plan to pre-approve the continued inpatient psychiatric level of care. The Plan denied your request. The Plan says a continued inpatient psychiatric level of care is not medically necessary for the enrollee.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 continued inpatient psychiatric level of care. Our reviewer says that the continued inpatient psychiatric level of care is not medically reasonable and necessary. Our physician reviewer found this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 24, 2021 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors while being cooperative and compliant. 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 continued inpatient psychiatric level of care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued inpatient psychiatric level of care beginning September 24, 2021 forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a fluoride treatment (D1206) provided June 8, 2021.
You asked the Plan to pay for the fluoride treatment. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says the service at issue is not covered under the enrollee's medical 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 a fluoride treatment (D1206) provided June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower limb prostheses with K3 feet.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no clinical documentation describing your progression to a K3 ambulation status.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The records from your treating provider do not confirm the need for K3 level components and records indicate you walk with two canes or a walker which is not consistent with a K3 ambulatory level. Our physician reviewer found that your condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower limb prostheses with K3 feet.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomics panel testing provided on May 13, 2021.
You asked the Plan to pay for the testing services. You say that the testing allows physicians to make treatment decisions. The Plan denied your request. The Plan says the codes are not correct for the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics panel testing provided on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a cervical collar (L0174) provided on December 1, 2020.
You asked the Plan to pay for a cervical collar. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item 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 pay for a cervical collar. Our reviewer says that the
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not reveal objective physician progress notes indicating the need for the requested cervical collar. Without a clear history, physical, and rationale for the cervical collar from the enrollee's treating physician, the requested collar cannot be considered in accordance with accepted standards of medical practice for the diagnosis or treatment of the enrollee's condition, to improve the function of a malformed body member, or furnished in a setting appropriate to the enrollee's medical needs and condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a cervical collar have not been met. Therefore, we decided that the Plan does not have to pay for a cervical collar (L0174) provided on December 1, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care, for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee's doctor says that the enrollee continues to require intensive rehabilitation and monitoring at the inpatient rehabilitation facility (IRF), given the enrollee's extensive acute neurologic issues. The Plan states all the services the enrollee needs are offered at the IRF. The Plan states that transfer to a SNF for inpatient skilled rehabilitation services is not medically necessary.
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 enrollee no longer qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is consistently ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care, for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 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 SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from November 4, 2021,
forward.
You asked the Plan to pre-approve SNF care. You say that you are looking for continued coverage at the
facility. You state you still need physical therapy and want to continue your stay. You state it is medically
necessary because you are having a hard time walking. The Plan denied your request. The Plan says the stay is
not medically necessary.
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 no longer qualifies for SNF coverage.
You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You
are ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision.
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your
condition. Your care needs are custodial and, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve continuation of SNF care from November 4, 2021, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for inpatient hospital care received on May 11, 2021.
You asked the Plan to waive the cost-sharing for inpatient hospital care. You say that your out-of-pocket expenses keep going up and you would like the Plan to investigate the cost-sharing in this case. The Plan denied your request. The Plan says the claim for your inpatient hospital services processed 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 10% coinsurance after the $300 deductible is met for inpatient hospital care. You have been asked to pay a cost-share of $884.39 for inpatient hospital care. The Allowed Amount for these services was $6,143.85. $6,143.85 less the $300 deductible = $5,843.85. $5,843.85 X 10%= $584.39. Your $300 deductible plus $584.39 (10% coinsurance) = $884.39. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 10% coinsurance after the $300 deductible is met. 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 cost-sharing for inpatient hospital care received on May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says your appropriate therapy needs are clearly not precluded in an alternate 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 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 have a past medical
history of Parkinson's disease, head injury, and schizoaffective disorder who is living at home with functional decline and weakness. 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 the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electric stimulation therapy (97014) provided on April
16, 2021, through April 22, 2021.
You asked the Plan to pay for the electric stimulation therapy. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says CPT code 97014 has a status
indicator of I and is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 97014 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code 97014 has a status indicator of I. This means that CPT code 97014 is not valid for Medicare purposes.
Based on this information, we decided that Medicare rules for coverage of the electric stimulation therapy have
not been met. Therefore, we decided that the Plan does not have to pay for the electric stimulation therapy
(97014) provided on April 16, 2021, through April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retreatment of previous root canal therapy - molar (CPT
code D3348), retreatment of previous root canal therapy - premolar (CPT code D3347), and treatment of root
canal obstruction; non-surgical access (CPT code D3331).

You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain. You state you were
told that you would need to have a 3D exam done prior to them seeing you. You state that your cardiologist
said that you have abnormal palpitations and that they are not sure if that is being caused due to the infection
you have on your molars 28 and 31. The Plan denied your request. The Plan says the services are not a covered
benefit under the plan.

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. The services are not listed in your EOC/Dental Benefit Schedule as a
covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to
pre-approve retreatment of previous root canal therapy - molar (CPT code D3348), retreatment of previous root
canal therapy - premolar (CPT code D3347), and treatment of root canal obstruction; non-surgical access (CPT
code D3331).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from July 31, 2020, through August 5, 2020 with the reported secondary diagnosis J96.21, acute and chronic respiratory failure with hypoxia.
You asked the Plan to pay for inpatient services provided from July 31, 2020, through August 5, 2020 with the reported secondary diagnosis J96.21, acute and chronic respiratory failure with hypoxia. The Plan denied your request. The Plan says DRG 190 billed is not supported.
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 the secondary diagnosis J96.21, acute and chronic respiratory failure with hypoxia. 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 inpatient services provided with the reported secondary diagnosis J96.21, Acute and chronic respiratory failure with hypoxia. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the documentation submitted does not support a diagnosis of acute and chronic respiratory failure with hypoxia. The documentation upon admission July 31, 2020 documents chronic obstructive pulmonary disease with acute exacerbation (J44.2). Subsequent care for dates of service
August 1, 2020, through August 4, 2020 documents acute exacerbation (J44.2). The discharge documentation for dates of service August 5, 2020 documents acute and chronic respiratory failure with hypoxia (J96.21). The documentation does not support treatment for acute and chronic respiratory failure with hypoxia and therefore, this diagnosis cannot be confirmed. 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 inpatient services provided from July 31, 2020, through August 5, 2020 with the reported secondary diagnosis J96.21, acute and chronic respiratory failure with hypoxia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation with dental code D0140 provided
on April 23, 2021.
You asked the Plan to pay for dental code D0140. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says dental code D0140 is not covered under the
Plan's supplemental dental 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, dental code D0140 is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral
evaluation with dental code D0140 provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 26, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 file shows that the enrollee was seen for low back pain. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 26, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) services billed with Patient Driven Payment Model (PDPM) code GDPF1 x 14 provided on September 17, 2020, through October 9, 2020.

You asked the Plan to pay for the SNF services billed with PDPM GDPF1 x 14. You say that you would like
reconsideration because the medical records submitted support the PDPM code billed The Plan denied your request. The Plan says that the documentation submitted do not support the services as billed.

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. Specifically, the record indicates that the Plan reviewed medical records to identify inconsistencies between the clinical documentation and coding. The Plan has failed to forward medical records for review. We are unable to determine if coding criteria have been met without medical records. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) services billed with Patient Driven Payment Model (PDPM) code GDPF1 x 14 provided on September 17, 2020, through October 9, 2020.

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.