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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.

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 receiving appropriate care at the present acute care hospital. 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.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 31 additional Logisticare miles.

You asked the Plan to pre-approve additional mileage. You say that you currently see a team of doctors in
Chapel Hill, North Carolina. You also say that you were referred to them. The Plan denied your request. The
Plan says the shortest route to the provider's office is 84.5 miles. The Plan also says that this trip exceeds the
benefit mileage limit of 50 miles.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation when each one-way trip must not exceed 50 miles of driving
distance.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles
are not covered. Therefore, we decided that the Plan does not have to pre-approve 31 additional Logisticare
miles.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for neurolytic destruction of peripheral nerve of left foot provided on May
19, 2021.

You asked the Plan to pay for destruction by neurolytic agent; other peripheral nerve or branch (64640). You
say that the injection was necessary to relieve your foot pain. The Plan denied your request. The Plan says that
the claim was submitted with an incorrect procedure code.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.

You were referred for destruction by neurolytic agent; other peripheral nerve or branch (64640) by a contract
provider. The file does not show that the Plan provided notice that destruction by neurolytic agent; other
peripheral nerve or branch (64640) would not be covered. Under Medicare rules, this means destruction by
neurolytic agent; other peripheral nerve or branch (64640) is considered approved by the Plan. The coverage
articles cited by the Plan are not for your territory and therefore the Plan's argument is invalid. Therefore, we
decided that the Plan has to pay for neurolytic destruction of peripheral nerve of left foot provided on May 19,
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that you need to schedule the enrollee for the superion procedure at L2-3 and L3-4 to treat spinal stenosis because the enrollee's pain is 10/10. The Plan denied your request. The Plan says the services are considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis and neurogenic claudication. The record indicates that imaging has demonstrated multi-level degenerative disease including moderate to severe spinal stenosis at L2-L and L3-L4, the levels requested for treatment. The record indicates that the enrollee has had an interspinous spacer at the L4-L5 level. The record does not state that the enrollee is not indicated for operative intervention at more than two levels. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tooth extraction (D7140) provided on May 3, 2021.

You asked the Plan to pay for the extraction. You say that this service was necessary, and you were told by the
provider that there should be no problem having the Plan reimburse you. The Plan denied your request. The
Plan says this provider has chosen to opt-out of Original Medicare. Services received from a dental provider
who does not participate in the Medicare program will not be paid or reimbursed.

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. To use your dental benefits,
you may see any licensed dental provider who accepts Medicare patients in the United States and has not
opted-out of Original Medicare. If you use a provider that has opted-out of Medicare, you will not receive
reimbursement.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from a
provider who does not participate in the Medicare program are not covered under this benefit. Therefore, we
decided that the Plan does not have to pay for the tooth extraction (D7140) provided on May 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services provided on June 7, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the service was not billed with an appropriate revenue code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

In this case, the CPT Code Manual definition of code 90837 is Psychotherapy, 60 minutes with patient.

We find that CPT code 90837 was billed with a revenue code 0900, which signifies mental health treatments and services. Based on this information, we decided that Medicare rules for coverage of the services provided have been met. Therefore, we decided that the Plan has to pay for the psychotherapy services provided on June 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided by a non-contracted provider on February 5, 2020, to February 7, 2020.

You asked the Plan to pay for inpatient hospital care. You say that this diagnosis is supported by the medical records. The Plan denied your request. The Plan says diagnosis code for acute kidney failure 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 N17.9, Acute Kidney Injury, unspecified. 

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 hospital care. Our reviewer says that the diagnosis of N17.9, acute kidney injury is not supported in the documentation. Our physician reviewer found Acute kidney injury is defined as a rise of 3 times baseline which was not noted in this hospitalization. 

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 hospital care provided by a non-contracted provider on February 5, 2020, to February 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part-time basis appear appropriate in this case. 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 pay for the unspecified adjunctive procedure provided on February
9, 2021.
You asked the Plan to pay for the unspecified adjunctive procedure. You say that you paid the cost because the
doctor did not accept your insurance. You say that you could not eat, and this was the first doctor you could
find. The Plan denied your request. The Plan says the partial dentures were reimbursed in the amount of $1,100
and the unspecified adjunctive procedure 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
unspecified adjunctive procedure provided on February 9, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.

You asked the Plan to pre-approve CT scan. You say that your primary care provider ordered this test and you feel it is a necessary procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the records do not show how this test will impact your treatment and why other tests cannot be done first.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 CT scan. Our reviewer says that you do not meet the Medicare criteria for this CT scan. Our physician reviewer found you were diagnosed with cough, fever, COVID-19, and fatigue without improvement for the past 3 weeks. Based on the evidence, you are gradually improving from COVID-19 which often shows persistent symptoms over long periods. There were no signs or symptoms suggestive of another cause of your symptoms or that further investigation is needed as the symptoms are gradually improving. Therefore, this CT scan is considered 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.
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 you are ready to go to the inpatient rehab so that you can get physical therapy, gain some of your strength/independence back and then return home safely. The Plan denied your request. The Plan says that your needs can be met at lower 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.

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 respiratory failure and coronavirus pneumonia. 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 the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided on April 27,
2021.

You asked the Plan to waive the copayment for physician services. You say that you were seen for a wellness
exam. You also say you should not have a copay. The Plan denied your request. The Plan says you have been
asked to pay the correct cost sharing amount.

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 $20
copayment for each visit for physician services.

You have been asked to pay $10, which is less than the $20 copayment for physician services. Physician
services falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category.
The record shows the physician services you received went beyond the scope of a wellness visit. 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 physician services provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility care provided on February 1, 2021.

You asked the Plan to pay for skilled nursing facility care. You say that this has been billed multiple times. The Plan denied your request. The Plan says this cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

For Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. No medical records have been submitted to verify the billed service. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility care provided on February 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services you received from May 14, 2021, to June 17, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that this care was authorized, so it should be covered 100%. 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 $0 copayment per day for days 1-20, and a $160 copayment per day for days 21-100 for skilled nursing facility care.
Records show that you were in the SNF for a total of 34 days. You were not charged a copayment for the first 20 days of this stay. You have been asked to pay a copayment of $160 per day for the remaining 14 days, for a total of $2240. 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 skilled nursing facility (SNF) services you received from May 14, 2021, to June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 10, 2021, by an OON
provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.

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 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 the office visit provided on February 10, 2021, by
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a Coflex interspinous device for the
enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that the clinical value and effectiveness of the Coflex Interspinous
device in the setting of spinal surgery has not been demonstrated in the peer-reviewed literature.
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 coflex device is
experimental. More research is needed to show safety and efficacy. High failure rates with similar devices have
been reported. Our physician reviewer found that the enrollee's 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 insertion of a Coflex interspinous device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
You asked the Plan to pre-approve Eliquis. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.
Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.