Persius/hicric huggingface dataset:
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 clinical information provided supports the need for care in an LTACH. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee's care can be provided in the current inpatient hospital.
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 CoViD-19. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee's long-term prognosis and ventilator weanability appear to be poor. There is no evidence that the enrollee requires services that are not currently available. 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/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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular gene panel provided on June 9,
2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says there is no
documentation to indicate why the testing was ordered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

We looked at the file and the rules. Pre-symptomatic genetic tests and services used to detect an undiagnosed
disease or disease predisposition are not a covered benefit. It appears that the testing services was requested for
screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the
Plan does not have to pay for the hereditary cardiovascular gene panel provided on June 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that the enrollee is unable to
consistently perform her home program due to poor cognition and understanding. You say that additional
services are medically necessary. The Plan denied your request. The Plan says additional visits are not
medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional physical therapy visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that further therapy will not achieve any significant
improvement in the enrollee's symptoms or functional status. Our reviewer says that the unique skills of a
professional therapist are not required to safely and effectively provide ongoing treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have waive the copayments applied to ambulance services provided on July
15 - August 25, 2020.
You asked the Plan waive the copayments applied to the ambulance services. You say that you did not know
that it was your responsibility to make sure that transportation was provided by an authorized company. You
say that when services are not covered, it is the responsibility of the provider to advise the patient or caregiver.
The Plan denied your request. The Plan says the copayments were appropriately applied to the services
provided
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $150 copayment per one-way trip for ambulance services.
The enrollee has been asked to pay a $150 copayment per one-way trip for the ambulance services. The
ambulance services fall within the ambulance services benefit category. This means that the enrollee has been
asked to pay the correct amounts based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not
have waive the copayments applied to ambulance services provided on July 15 - August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays (D0220, D0230), fixed partial denture sectioning (D9120), guided tissue regeneration (D4266) and osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950) provided on July 29, 2021.

You asked the Plan to pay for the dental services. You say that these services were necessary. The Plan denied your request. The Plan says intraoral x-rays are a covered service, but this type of x-ray is limited to one procedure per year. You had a previous intraoral x-ray done in 2021, which was covered by the Plan at that time. The remaining services are not covered by your 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, the requested items or services are not among those covered under this benefit or are requested in a frequency that exceeds what is covered by the benefit. Documentation shows that you had a previous intraoral x-ray in 2021 which was covered by the Plan. Therefore, we decided that the Plan does not have to pay for the intraoral x-rays (D0220, D0230), fixed partial denture sectioning (D9120), guided tissue regeneration (D4266) and osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950) provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99211) therapeutic, prophylactic, or diagnostic injection (96372) and injection, ketorolac tromethamine, per 15 mg (J1885) provided on August 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you request reconsideration of your claim considering the necessity of the service with the attached supporting medical records. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 has network providers available who can provide 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 outpatient office visit (99211) therapeutic, prophylactic, or diagnostic injection (96372) and injection, ketorolac tromethamine, per 15 mg (J1885) provided on August 3, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular genomic testing (81286, 81238, 81410 and 81411) provided on May 20, 2021.

You asked the Plan to pay for the cardiovascular genomic testing. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says the member's physician did not order these lab services and the specimen was collected in a home setting.

The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular genomic testing have not been met. Specifically, the record indicates that the member's treating physician did not order this testing. Additionally, the record indicates that the specimen for this testing was rendered in a home setting, so the laboratory place of service code is not appropriate. Therefore, we decided that the Plan does not have to pay for the cardiovascular genomic testing (81286, 81238, 81410 and 81411) provided on May 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services provided on July 2, 2020.
You asked the Plan to pay for the air ambulance services. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the air ambulance services. Our reviewer says that the requested air ambulance services are not medically reasonable and necessary. Our physician reviewer found that there were no obvious injuries from falling, and the enrollee was moving all his extremities. The enrollee had unremarkable vital signs, and an adequate SpO2. The documentation does not support that the enrollee's illness or injury contraindicated transportation by any means other than ambulance. The documentation does not support that the enrollee's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health.
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 air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance services provided on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (93306) provided on August 24, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).
You have been asked to pay a $110 copayment for the Medicare-covered radiological diagnostic service provided. 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 the transthoracic echocardiography (93306) provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the technical component of the neuromonitoring services
provided on July 27, 2021.

You asked the Plan to pay for neuromonitoring services. You say that you would like this claim reprocessed
based on the medical documentation. The Plan denied your request. The Plan says this claim is not payable as
billed.

The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or
hospital for services furnished to the beneficiary while an inpatient.

We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we
decided that the Plan does not have to pay for the technical component of the neuromonitoring services
provided on July 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of Vertiflex Superion device.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by Medicare.

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 vertiflex spacer is experimental. More research is needed to show safety and efficacy. 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 the insertion of Vertiflex Superion device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. 

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: 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 IRF care is medically necessary. The Plan denied
your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met 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 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member does not require close supervision by a physician.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are necessary. The Plan denied your request. The Plan says that the patient would be safely and equally served at an alternative 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 above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for gastrointestinal bleeding. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten additional home visits for the enrollee.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says the approved visits should be enough to complete goals, learn a home exercise program, and establish a safe discharge plan.

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 the additional visits. Our reviewer says that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found the enrollee does not have documented ongoing home health physical therapy needs. The enrollee is mobilizing at a level commensurate with a lower level of care (i.e. home exercise program, outpatient therapy). As such, the requested ongoing home health physical therapy are 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten additional home visits for the enrollee.