Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.

You asked the Plan to pre-approve the IRF care. You say that you really need this service when you are discharged from the hospital. You also say that you need to go to a home that will provide physical therapy because you are weak and feel you need to be in this rehabilitation for a couple of weeks. The Plan denied your request. The Plan says the criteria for an admission to the acute inpatient rehabilitation setting 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 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 a intensive, multi-disciplinary rehabilitation program. Our physician reviewer also found that 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 the acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits, and the glucose monitoring analysis provided on April 14, 2021 and April 27, 2021.

You asked the Plan to waive the copayments for the specialist office visits and the glucose monitoring analysis. You say that there should be a $0 copayment for the glucometer. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for each specialist visit.

The enrollee has been asked to pay $63.62 copayment for the specialist office visits and the glucose monitoring analysis. The specialist office visits, and the glucose monitoring analysis fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were charged for office visits and a glucose monitoring analysis which are considered physician services.

This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the specialist office visits, and the glucose monitoring analysis provided on April 14, 2021 and April 27, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that your medical needs are being met in the current acute 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. LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. You are receiving acute hospital care, and acute care services have not been denied. The documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 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 pay for the services provided on January 28, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. The rules also say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. 

We looked at the file and Medicare rules. After review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Wisconsin. Additionally, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. 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 pay for the services provided on January 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transportation.

You asked the Plan to pre-approve ambulance transportation. You say that you need transportation to your physician's appointment. The Plan denied your request. The Plan says that transportation to a physician's office is not covered.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance transportation. Our reviewer says that ambulance transportation is not medically reasonable and necessary in this case. The record indicates that you are wheelchair bound and need transportation to your oncologist's office. The record does not indicate why other modes of transportation are contraindicated. Our physician reviewer found that your condition does not meet Medicare criteria for ambulance transportation. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve ambulance transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and sleeves (E0673) provided to the enrollee on September 25, 2020.

You asked the Plan to pay for the pneumatic compression device and sleeves. You say that this was requested by the enrollee's physician for use during surgery. The Plan denied your request. The Plan says that this is not covered by Medicare.

The Plan must follow Medicare rules. The rules state that a Pneumatic Compression Device (PCD) coded as E0675 to treat peripheral arterial disease (PAD) is not eligible for reimbursement.

We looked at the file and Medicare rules. Specifically, this item is not a covered benefit of Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and sleeves (E0673) provided to the enrollee on September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and electrocardiogram (EKG) provided on February 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for office visit and EKG. You say that this provider is the enrollee's primary care provider and does not require authorization. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.

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 an office visit and electrocardiogram (EKG) provided on February 26, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared therapy provided on November 30, 2020 and December 7, 2020.

You asked the Plan to pay for application of a modality to 1 or more areas; infrared (97026). You say that the enrollee needed infrared therapy for pain relief. The Plan denied your request. The Plan says infrared therapy is considered not reasonable and necessary by Medicare and is excluded from coverage.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Medicare does not cover infrared therapy. Based on this information, we decided that Medicare rules for coverage of application of a modality to 1 or more areas; infrared (97026) have not been met. Therefore, we decided that the Plan does not have to pay for infrared therapy provided on November 30, 2020 and December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6057, D6062).

You asked the Plan to pre-approve the services. You say that tooth #19 is an exposed implant that needs a cap or crown over the existing implant to be able to eat properly. The Plan denied your request. The Plan says this 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 pre-approve dental services (D6057, D6062).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided on March 23, 2021.

You asked the Plan to waive the copayment for emergency room services. You say that you were admitted to the hospital that same day. You also state that your insurance states if you go to the emergency room and then are admitted to the hospital, the copayment for the emergency room is waived. 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 $90 copayment for Emergency Care. Your contract also clearly says that you are not considered inpatient unless your provider writes an order to admit you as an inpatient. 

You have been asked to pay $90 copayment for emergency room services. Emergency room services fall within the Emergency Care benefit category. The record shows you were not admitted as an inpatient. Also, the record shows that the provider confirmed that you were admitted for outpatient observation. 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 emergency room services provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740) and periodontal scaling and root planing (D4341).

You asked the Plan to pre-approve the porcelain/ceramic crown and periodontal scaling and root planing. You say that these services are necessary due to the quality of past dental work. The Plan denied your request. The Plan says these services have been exhausted for the dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the porcelain/ceramic crown twice per calendar year and periodontal scaling and root planing once per quadrant per calendar year. 

We looked at the file and Medicare rules. In this case, the requested procedures have already been processed and paid for the 2021 calendar year. Therefore, the benefit has been exhausted for the requested services. Based on this information, we decided that the Plan's rules for coverage of the porcelain/ceramic crown and periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740) and periodontal scaling and root planing (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D0393).

You asked the Plan to pre-approve the services. You say that you need implants and your gums are shrinking. The Plan denied your request. The Plan says this 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 pre-approve dental services (D0393).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and complete series of intraoral x-rays (D0210) provided on February 15, 2021.

You asked the Plan to pay for the periodic oral evaluation and complete series of intraoral x-rays. You say that this examination was for a dental clearance required by your cardiac surgeon prior to receiving a Transcatheter Aortic Valve Replacement surgery. The Plan denied your request. The Plan says these services are purely dental in nature and are unrelated to the limited clinical indications. The Plan also says that these services are not eligible for coverage under the medical benefit.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and complete series of intraoral x-rays (D0210) provided on February 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy (PT) services provided May 12, 2021.

You asked the Plan to pay for the PT services. You say that please reprocess the claims. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria for physical therapy services.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the PT services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on review of the available records, the enrollee does not meet CMS/LCD coverage criteria for the services provided by a PT. The enrollee was referred for Vestibular rehabilitation and services provided did not address the Vestibular function. The PT notes were illegible and from what can be gathered the enrollee was treated with exercises for back pain and some evaluation for instance Berg balance test were performed. The documentation of services does not support specific the therapy prescription for coverage for the therapy visits. 

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 PT services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy (PT) services provided May 12, 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 you are unable to walk and take care of yourself. The Plan denied your request. The Plan says the stay is not medically necessary.

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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lumbar spine surgery complicated by post-operative respiratory failure and pneumonia. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
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 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. The enrollee does 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. 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.