Persius/hicric huggingface dataset:
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different 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 based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an 
IRF 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on February 28, 2021.
You asked the Plan to pay for the psychotherapy services. You say that the records support the medical necessity of this visit. The Plan denied your request. The Plan says there is no documentation of a consultation with the attending physician.
The Plan must follow Medicare rules. Medicare rules say that CPs are required to document a consultation with the primary or attending physician or the attempt to make such a consultation.
There is no documentation in this record supporting consultation or attempt at consultation was performed. Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on February 28, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the ultrasound services provided on November 10, 2020. 
 
You asked the Plan to pay for the ultrasound services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the services billed are a duplicate. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the case file submitted by the Plan is largely 
incomplete. The case file is missing required documentation such as the case narrative, medical records, and 
notice of denial of payment. One document in the case file states that the claim was denied as duplicate; 
however, the documentation does not include any other documentation to support that these services billed 
were a duplicate. The plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for 
the ultrasound services provided on November 10, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exercise bike.
You asked the Plan to pre-approve an exercise bike. You say that due to Coronavirus you are unable to go to a gym and receive the fitness benefit reimbursement. The Plan denied your request. The Plan says an exercise bike is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because an exercise bike is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve an exercise bike.
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 the 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 were admitted for osteomyelitis of the tibia and femur and had above the
knee amputation. 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.
In conclusion, 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: 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 you do not require skilled nursing or therapy 
services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.

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 service at issue in this appeal.

We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to hold you harmless for an office visit and a mouth x-ray. We decided that the 
Plan does not have to pay for 2 teeth extractions.  
 
You asked the Plan to pay for an office visit, 2 extractions and a mouth x-ray. You say that the denied services 
were based on a referral because the procedure would be too complicated to be handled by a regular dentist. 
You also say this was considered surgery and the Plan should cover all or part of the cost. The Plan denied your 
request. The Plan says the service in question is not covered under your contract under any normal 
circumstances. 
 
We decided that the Plan has to hold you harmless for an office visit and a mouth x-ray.  
 
The Plan follows Medicare rules. Medicare rules say that when a plan provider gives, or refers an enrollee for, 
a service that the enrollee reasonably believes is covered by the plan, the enrollee is held harmless and need not 
pay more than the plan-allowed cost-sharing for that service.  
 
We looked at your request, the file and Medicare rules. The record indicates that these services were rendered 
by a plan provider. You must be held harmless as these services are covered benefits with your Plan. Services 
and referrals obtained from a plan provider are viewed as plan-approved unless notice is given that the services 
will not be covered. They can do that by either paying you directly for the difference, or by directing the 
provider to do so. Therefore, we decided that the Plan has to hold you harmless for an office visit and a mouth 
x-ray.  
 
We also decided that the Plan does not have to pay for 2 teeth extractions. 
 
The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit 
includes two (2) oral exams, two (2) cleanings and one (1) dental x-ray per calendar year. This benefit does not 
include extractions. Therefore, we decided that the Plan does not have to pay for 2 teeth extractions. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional acupuncture services. 
 
You asked the Plan to pre-approve these services. You say that you need more visits to improve your condition. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case.  
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the Plan covers no more than 20 sessions per year. 
Further treatments are not covered by Medicare or your supplemental benefit. Therefore, we decided that the 
Plan does not have to pre-approve additional acupuncture services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that The Plan denied your request. The Plan says that the records do not show that the enrollee required daily skilled nursing or skilled therapy in a SNF setting. The Plan says that the enrollee's medical issues appear essentially stabilized.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records, which their denial reason states they reviewed and based their decision on. The Plan did not provide proper evidence of having made reasonable attempts to obtain medical records. We made multiple attempts to retrieve the medical records from the Plan. We also made multiple attempts to retrieve call logs, fax receipts, or copies of mailed correspondence demonstrating that the Plan did their due diligence in trying to obtain medical records from your provider(s) for this review. None of this documentation was supplied prior to the deadline for our decision. Without this information, we do not have the information that is needed to determine whether the Plan's denial was justified. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) services.
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 the inpatient hospital services rendered from November 8, 
2020 to November 15, 2020. 
 
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 submitted records do not support the billing of diagnosis code G93.41. 
 
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 diagnosis code G93.41 (metabolic encephalopathy). 
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 these services. Our reviewer says that the 
submitted records do not support the billing of diagnosis code G93.41. Our physician reviewer found the 
enrollee was diagnosed with and treated for a urinary tract infection (UTI). She was previously experiencing 
hallucinations that were being worked up and thought to be related to schizophrenia and/or dementia and not 
from the UTI. The records do not support the billing of secondary diagnosis code G93.41.  
 
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 the inpatient hospital services rendered from November 8, 2020 to November 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.

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 service at issue in this appeal.

We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 20, 2021, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 20, 2021, 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 October 
20, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of October 20, 2021, forward. Our physician reviewer found you did not 
require inpatient mental health treatment beyond October 20, 2021, 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 beyond the date in question. 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 October 20, 2021, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 20, 
2021, forward.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the targeted genomic sequence analysis (0037U) provided
January 12, 2021.
You asked the Plan to pay for the targeted genomic sequence analysis. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that Medicare does not separately pay any provider or supplier for services furnished to the beneficiary pre-procedure in preparation for, during, or following a procedure or surgery.
The Plan must follow Medicare rules. Medicare rules say that the rules for the date of service at an advanced diagnostic laboratory are subject to the criteria in the Medicare rules section. We looked at the file and Medicare rules. In this case, this testing was done on a biopsy provided in a facility, that was taken on June 23, 2020. The testing was not ordered until December 28, 2020. Since it is more than a month after the facility services, the cost is not considered to be part of the facility service. The provider is allowed to bill with a non-facility POS code and a date of service that is not when the specimen was taken, as it was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter. Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis have been met. Therefore, we decided that the Plan has to pay for the targeted genomic sequence analysis (0037U) provided January 12, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump.

You asked the Plan to pre-approve these services. You say that you have an incomplete rotator cuff tear. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and necessary.

We looked at the file and Medicare rules. The services at issue are a fluid circulating cold pad with pump described by code E0218. This item is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump.