Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) services billed with Patient-Driven Payment Model (PDPM) Score JADE1 x 30 days, JADE1 x 31 days & JADE1 x 15 days provided September 1, 2020 to November 16, 2020.  You asked the Plan to pay for the SNF services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers must report skilled nursing services with the appropriate PDPM score.  In this case, the claim was billed with PDPM Score JADE1 for 30 days, JADE1 for 31 days and JADE1 for 15 days. 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 SNF services. Our reviewer says that the documentation does not support the services billed. Our physician reviewer found the enrollee has a past medical history of carcinoma in situ of the anus and anal canal, unspecified open wound of the left lower leg, muscle weakness, adjustment disorder with anxious and depressed mood, and was receiving care in a skilled nursing facility. The documentation does not support the billing of PDPM Score JADE1 x 30 days, JADE1 x 31 days & JADE1 x 15 days. Provided records do not document malnutrition as a diagnosis or risk factor for the enrollee or that respiratory treatment was provided as required for the PDPM score billed.  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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services billed with Patient-Driven Payment Model (PDPM) Score JADE1 x 30 days, JADE1 x 31 days & JADE1 x 15 days provided September 1, 2020 to November 16, 2020.
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. The Plan denied your request. The Plan says you do not require a coordinated team approach.  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 physician reviewer found that you had bilateral total knee arthroplasties in May of 2021. The post-operative course was complicated by a non-healing wound that required the use of a wound vac. You continue to have a need for skilled therapy with a potential for functional improvement.  However, the documentation does not support that you require skilled rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your functional status.  You are ambulating with minimal assistance. You are near your prior level of function.   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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical placement of a mini implant (D6013 x 4), precision attachments (D5862 x 4), and an implant supported removable denture (D6111).  You asked the Plan to pre-approve the dental services. You say that the enrollee's existing upper denture is 10 years old. You say that the enrollee has not worn it in the last 2 years. You also say that the enrollee would benefit from having lower mini implants to stabilized their lower denture. The Plan denied your request. The Plan says surgical placement of mini implant is not listed as a covered service. The Plan says that precision attachment is not listed as a covered service. The Plan says that implant supported removable denture is not listed as a covered service either.  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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of a mini implant (D6013 x 4), precision attachments (D5862 x 4), and an implant supported removable denture (D6111).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a consultation and testing to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a consultation and testing to be provided by an OON provider. You say that the requested consultation and testing with an OON provider is medically necessary. The Plan denied your request. The Plan says the requested consultation and testing with an OON provider is not medically necessary.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.   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 a consultation and testing to be provided by an OON provider. Our reviewer says that the requested consultation and testing with an OON provider is not medically necessary. Our physician reviewer found this enrollee is not currently receiving any active treatment and/or medical management of his/her condition that makes it medically necessary for this enrollee to continue care with the out-of-network provider as requested. There is nothing unique about this enrollee's condition that would make it medically necessary for him to continue care with the requested OON provider. The Plan has shown that they have in-network tertiary level urology specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of the enrollee's condition. This enrollee's medical management and/or follow-up care can be safely transitioned to an in-network tertiary level urology specialist at this time.  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 consultation and testing to be provided by an OON provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation and testing to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for an emergency department visit and a computed tomography (CT) scan provided on August 25, 2021.  You asked the Plan to waive the copayments for the emergency department visit and CT scan. You say that computed tomography (CT) scans have always been included in the emergency department copayment. The Plan denied your request. The Plan says you have been charged 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 $90 copayment for each emergency department visit.   Your contract with the Plan also clearly states that you must pay a $300 copayment for outpatient diagnostic tests, including computed tomography (CT) scans.  You have been asked to pay a $90 copayment for the emergency department visit. Emergency department visits fall within the Emergency Care benefit category. You have also been asked to pay $300 for the CT scan. CT scans fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The total for your stay is $390. 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 copayments for an emergency department visit and a computed tomography (CT) scan provided on August 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy services coded S9367 provided from May 27, 2021 to June 2, 2021.  You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code S9367 is home infusion therapy, total parenteral nutrition (tpn); more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard tpn formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem.  We find that CPT code S9367 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9367 provided from May 27, 2021 to June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial upper denture (D5213).  You asked the Plan to pre-approve the dental item. You say that you need this denture to help your mouth. The Plan denied your request. The Plan says 1 partial upper denture is covered every 5 plan years. The Plan also says that the frequency limit has been reached.  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.  We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental item have not been met. Specifically, the frequency limit has been exceeded. The record shows that the Plan paid for a partial upper denture that you received on October 31, 2017. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiologic examination (74018) provided on August 2, 2021.  You asked the Plan to pay for code 74018. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 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. In this case, we have confirmed that code 74018 is a column II code to column I code 74019. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the radiologic examination (74018) provided on August 2, 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 services are medically necessary as the enrollee's overall recovery depends on the approval of rehabilitation services. The Plan denied your request. The Plan says that based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.  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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 the enrollee 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve oral hygiene instructions (D1330).  You asked the Plan to pre-approve the dental service. You say that you feel that this service should be covered. The Plan denied your request. The Plan says oral hygiene instructions are not a covered service.  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 oral hygiene instruction is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve oral hygiene instructions (D1330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve replacement eyeglasses.  You asked the Plan to pre-approve replacement eyeglasses. You say that you cannot see, you have headaches, you are off balance and nauseous. The Plan denied your request. The Plan says you received a pair of glasses (Bifocal lenses and frames) on February 17, 2021, and you are not eligible for another pair of eyeglasses in 2021. A second pair of glasses exceeds the enhanced routine vision benefit limit of one pair of glasses of contact lenses per calendar year.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that you received a pair of glasses (Bifocal lenses and frames) on February 17, 2021, and you are not eligible for another pair of eyeglasses in 2021. Based on this information, we decided that the Plan's rules for coverage of replacement eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement eyeglasses.
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 requires LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care; and is currently unstable for transfer to LTACH.  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 does not appear to be stable for transfer to an LTACH given the present respiratory instability. There is no documentation provided indicating medical necessity for LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve thoracic oncology services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve thoracic oncology services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF care. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.  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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 the enrollee 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services (99238) provided January 18, 2021.  You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed cannot be paid.  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 99238 is not supported in the medical record. Specifically, the billed code was already paid on another claim for this date of service. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99238) provided January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 10 additional non-emergency, routine transportation trips (A0120).  You asked the Plan to pre-approve the additional routine transportation. You say that you need additional trips for doctors' visits. The Plan denied your request. The Plan says the requested number of trips exceeds the limit listed by the Plan.  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 a maximum of up to 52 one-way trips per year.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 10 additional non-emergency, routine transportation trips (A0120).