Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a tooth extraction (D7140) and an intraoral periapical first radiographic image (D0220) provided on April 22, 2021, by an OON provider.  You asked the Plan to pay for a tooth extraction and an intraoral periapical first radiographic image. You say that services should not have been performed if the provider knew they were out of network. You also say that you thought the provider was in network and you should not be responsible for this bill. The Plan denied your request. The Plan says services are only covered when received by a participating provider.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a tooth extraction and an intraoral periapical first radiographic image when the services are received by a participating provider.   We looked at the file and Medicare rules. Specifically, the services were rendered by an OON provider. Based on this information, we decided that the Plan's rules for coverage of a tooth extraction and an intraoral periapical first radiographic image have not been met. Therefore, we decided that the Plan does not have to pay for a tooth extraction (D7140) and an intraoral periapical first radiographic image (D0220) provided on April 22, 2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from March 26, 2021, through March 27, 2021.
You asked the Plan to pay for inpatient hospital care. You say that you are requesting reconsideration of the referenced claim. The Plan denied your request. The Plan says the clinical documentation does not support that the following diagnosis impacted this hospital admission- I50.42- chronic combined systolic (congestive) and diastolic (congestive) heart failure, and I47.2-ventricular tachycardia.
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 I50.42- chronic combined systolic (congestive) and diastolic (congestive) heart failure, and I47.2-ventricular tachycardia. 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 physician reviewer found the review has determined that the enrollee tolerated the procedure well with no complications. The enrollee was transferred to SICU for overnight monitoring. The enrollee is grossly neurologically intact with strength 5 out of 5 in upper and lower extremities, tongue is midline, no facial droop or slurred speech and the enrollee denies amaurosis fugax. The enrollee is now stable for discharge to home. The review has determined that the clinical documentation did not support that the following diagnosis impacted this hospital admission- I50.42- chronic combined systolic (congestive) and diastolic (congestive) heart failure, and I47.2-ventricular tachycardia. 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 from March 26, 2021, through March 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (CPT code 88120) provided to the enrollee on March 18, 2021.  You asked the Plan to pay for the service. You say that the service was necessary. The Plan denied your request. The Plan says the service was not necessary.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Results from the Urovysion Kit are intended for use, in conjunction with and not in lieu of current standard diagnostic procedures, as an aid for  initial diagnosis of bladder carcinoma in patients with hematuria and subsequent monitoring for tumor recurrence in patients previously diagnosed with bladder cancer. Therefore, we decided that the Plan does not have to pay for cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (CPT code 88120) provided to the enrollee on March 18, 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 this is medically necessary. The Plan denied your request. The Plan says you can be treated at a 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. Our physician reviewer found while you require physical therapy and occupational therapy services, based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. There is no documentation that you require the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears 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 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.
You asked the Plan to pre-approve IRF care. You say that you need inpatient rehabilitation services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The necessary services can safely be provided in an alternate setting.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 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.  

You asked the Plan to pre-approve IRF care. You say that you need IRF care. 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 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 that you do not require the intensity of services provided at an IRF.  Specifically, you have not been shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomic testing provided on May 12, 2021.
You asked the Plan to pay for the pharmacogenomic testing. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says this service was not medically
necessary.
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 the pharmacogenomic testing. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the provided records did not clearly support this genetic testing or revealed the
purpose of it such as how it might change his treatment plan or overall outcome. There is insufficient evidence
currently available to support genetic testing to improve overall outcomes.
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 pharmacogenomic testing have not been met. Therefore, we decided that the
Plan does not have to pay for the pharmacogenomic testing provided on May 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 20, 2022,
forward.
You asked the Plan to pre-approve inpatient psychiatric care from January 20, 2022, forward. You say that the
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are
not medically necessary.
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 inpatient psychiatric care from January
20, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health
treatment for the date in question of January 20, 2022, forward. Our physician reviewer found you did not
require inpatient mental health treatment from January 20, 2022, forward, as you were not a danger to yourself
or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active
treatment was taking place. It did not appear that the services for the dates in question were reasonably
expected or medically necessary to improve your condition or for the purpose of diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care from January 20, 2022, forward have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 20,
2022, forward.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 22, 2021, to July 29, 2021.

You asked the Plan to pay for the acute inpatient hospital care. You say that you would like this denial to be reconsidered. The Plan denied your request. The Plan says that the information provided does not show that the enrollee had severely elevated blood acid levels, severe confusion that did not improve, or need for an infusion of insulin through the vein.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record did show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 

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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 22, 2021, to July 29, 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 pre-approve inpatient level of care for knee surgery.
You asked the Plan to pre-approve acute inpatient hospital level of care. You say that inpatient care is
medically necessary. The Plan denied your request. The Plan says the surgery can be provided at a lower level
of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital level of care.
Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case.
Our physician reviewer found there is no documentation provided to support the expectation the enrollee will
require a greater than 2 midnight stay. The total knee arthroplasty can be safely provided at a lower level of
care than inpatient.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital level of care have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient level of care for knee surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient hospital care.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a combined anteroposterior colporrhaphy and sacrospinous ligament fixation for prolapse of vagina and will need inpatient admission after surgery. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is approved for a combined anteroposterior colporrhaphy and sacrospinous ligament fixation for prolapse of vagina. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for an oncology consultation.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers available.

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 an out-of-network referral for an oncology consultation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee's complex medical needs
require ongoing acute care. The Plan denied your request. The Plan says LTACH care 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 in this case the record indicates that the enrollee still requires ventilator support
and is being weaned.

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 he is not currently receiving but that would be available at
the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) home health (HH) skilled nursing (SN) services (CPT code G0299 x 8), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee's records do not support the need for a skilled nurse to make more visits.
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 services. Our physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy). The enrollee's needs appear to be long-term and custodial. As such, the requested, ongoing HH SN services are not medically necessary or reasonable. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) home health (HH) skilled nursing (SN) services (CPT code G0299 x 8), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the LTACH admission criteria. You say that the enrollee is stable and suitable for transfer to an LTACH, and she cannot be adequately cared for at a skilled nursing facility. The Plan denied your request. The Plan says the guidelines for LTACH care have not been met. The Plan says that the enrollee's needs can safely be met in the current hospital setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the short-term acute care hospital can provide for all of the patient's present inpatient care needs and the patient is receiving an appropriate level of care in the present setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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.