Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308, 99309) provided on October 25, 2021, to October 29, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that the service was provided with no adequate time frame to obtain authorization for the service. The medical records clearly reflect the medical necessity for the services rendered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 subsequent nursing facility care (99308, 99309) provided on October 25, 2021, to October 29, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation for physical therapy (PT) (97163, 97162) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a PT evaluation with an OON provider. You say that you have a special 
condition called EDS type 3. You also say that your condition meets criteria for you to see an OON provider 
due to not being able to see an in-network provider for three months, due to traveling restrictions. The Plan 
denied your request. The Plan says there are in-network providers available for these services. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 PT evaluation with an OON provider. Our reviewer says that the service is 
not approved with an OON provider. 
 Our physician reviewer found the documentation does not reveal an emergency or reasonable medical 
explanation why the requested medical service of outpatient PT needs to be done out of network. The 
documentation does not reveal that you are unable to receive the requested care in your network. 
 
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 PT evaluation with an OON provider have not been met.  
 
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 PT evaluation with an OON provider. Therefore, we 
decided that the Plan does not have to pre-approve an evaluation for physical therapy (PT) (97163, 97162) 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 IRF care is medically reasonable and necessary. 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 the complexity of the patient's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's
current medical condition does not require intensive physician or nursing supervision in an IRF. The patient
may benefit from additional physical and occupational therapy, but the documentation does not reveal that this
therapy must be only on an intensive level in an IRF. The documentation does not support that the patient has
the activity tolerance for an intensive IRF therapy 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.
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 IRF care is medically necessary. The Plan denied
your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the
enrollee's needed care can be provided at a lower level.
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. There is not a reasonable expectation that this 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 pre-approve a medical eye exam (92004) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a medical eye exam. You say that this care is medically necessary. The Plan 
denied your request. The Plan says there are in-network providers that are available to meet the enrollee's 
needs. 
 
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 
a medical eye exam (92004) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Crestor 20 mg tablet. 
 
You asked the Plan to pre-approve Crestor. You say that this is medically necessary for the enrollee's condition. 
The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the 
enrollee's medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Crestor 20 mg tablet.  
 Benefits for Crestor may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
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 does not meet criteria.

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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require at least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days, of therapy services. While the enrollee may be able to participate in an intensive rehabilitation therapy program, the documentation supports that the services could be provided 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after February 27, 
2022. 
 
You asked the Plan to pre-approve SNF care after February 27, 2022. You say that the requested admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is 
not medically necessary. 
 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 after February 27, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) 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 after February 27, 2022, have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) care after February 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B injections (Q5119,
J1569) provided on September 28, 2021, to October 11, 2021.
You asked the Plan to waive the coinsurance for injections. You say that you received prior authorization for
the services. You also mention the website indicates you have a 0% coinsurance. The Plan denied your request.
The Plan says the cost-share was applied correctly. The Plan explains that the 0% coinsurance information you
found is just an overview, not an all-inclusive benefit.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Medicare Part B Prescription Drugs. You have been asked to pay a 20% coinsurance in the amount of $2440.08 for Medicare Part B injections
(Allowed amount for both claims = $16,420.80  20% = $3,284.16). The services at issue fall within the
Medicare Part B Prescription Drugs benefit category. Since the amount you have been asked to pay is less than
the contractually required payment, 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 coinsurance for Medicare Part B
injections (Q5119, J1569) provided on September 28, 2021, to October 11, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee's nursing, medical and rehabilitation needs do not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee will not be able to 
fully participate in, and benefit from, the intensive rehabilitation therapy program provided in an IRF. A lower 
level of services appears to be more appropriate. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) from an out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.

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 magnetic resonance imaging (MRI) from an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee on August 12, 2020, to
August 24, 2020, and billed under a secondary diagnosis of J95.1.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the Medicare billing criteria for these services were not met. 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. 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 Medicare billing criteria are not met. Our physician reviewer
found the medical record supported an admission for NSTEMI for which a CABG was performed. Subsequent
documentation consistently recorded no acute distress, adequate respiratory effort, unlabored respirations
without accessory muscle use or sternal retractions. Supplemental oxygen was utilized at low flow rates during
the post-operative period and was weaned to room air without incident. Review of the documentation was
incomplete to reflect evidence of significant, prolonged tachypnea, hypoxia refractive to low flow supplemental
oxygen, increased work of breathing, need for prolonged invasive or noninvasive ventilatory assistance, or
abnormal arterial or venous blood gas results consistent with acute pulmonary insufficiency to substantiate
reporting of J95.1 as an additional diagnosis. The review has determined that the records do not support the
billing of secondary diagnosis J95.1.
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 care provided to the enrollee on August 12, 2020, to August 24, 2020, and billed under a
secondary diagnosis of J95.1.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.
You asked the Plan to pre-approve inpatient psychiatric services. You say that the records provided support the
need for inpatient psychiatric services. The Plan denied your request. The Plan says the criteria for coverage
have not been met. The Plan says that the enrollee could be treated at a lower level of care.
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 services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee
was involuntarily admitted to the acute inpatient psychiatric hospitalization on February 21, 2022. It was not
expected this enrollee would improve in a reasonable period of time as she did not have dangerousness to self
or others and was not showing any auditory/visual hallucinations or any aggressive behaviors. It did not appear
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather
than a lower level of care as she did not have dangerousness to self or others. This enrollee did not appear to
require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with
care without any aggressive behaviors. It did not appear that the services were reasonably expected to improve
the enrollee's 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 services have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient psychiatric services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 25, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

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 $35 copayment for Physician/Practitioner services, including doctor's office visits.

You have been asked to pay a $35 copayment for the specialist office visit. the specialist office visit falls within the Physician/Practitioner services, including doctor's office visits benefit category. 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 a specialist office visit provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a panoramic radiographic image (D0330) provided on June 1, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a limited oral evaluation and a panoramic radiographic image. You say that you injured your teeth after a fall. You also say that you should have coverage for this emergency injury. The Plan denied your request. The Plan says there is no authorization on file for these services.

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 a limited oral evaluation (D0140) and a panoramic radiographic image (D0330) provided on June 1, 2021, by an out-of-network (OON) provider.