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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in a lower level of care. 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing or skilled therapy needs. You appear to have reached a new plateau in function. Daily skilled services are not required to establish a maintenance program, or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial, and as a practical matter, can 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 73565 provided on April 26, 2021.

You asked the Plan to pay for the x-ray 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 separately 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, we have confirmed that code 73565 for the x-ray services has a bundled relationship with code 73562 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 x-ray services coded 73565 provided on April 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
December 23, 2020.
You asked the Plan to pay for subsequent nursing facility care. You say that these visits are not pre-scheduled, and an authorization was not obtained prior to the services provided. The Plan denied your request. The Plan says all services obtained from out-of-network providers require prior authorization. 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on December 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that you are still in a lot of pain, are having issues walking and are not prepared to do the exercises at home by yourself. You say that physical therapy should be reinstated for 8 more sessions. The Plan denied your request. The Plan says additional visits are not medically necessary.
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 pre-approve 8 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you had prior therapy and participate in water therapy on your own. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
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 and appropriate for this enrollee. They cannot get the services they need in a lower level of care. The Plan denied your request. The Plan says the criteria for admission to an IRF have not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.

Our physician reviewer found 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. 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), scaling and root planing for 4 or more teeth per quadrant (D4341), and scaling and root planing for 1 to 3 teeth per quadrant (D4342) to be provided by a periodontist.

You asked the Plan to pre-approve the dental services. You say that your dentist advised that you needed a deep cleaning. You say that you have been bleeding from your gums. You also say that it is bothering you. The Plan denied your request. The Plan says dental services performed by a periodontist are not covered.

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, dental services performed by a periodontist are not among those covered under this benefit.

Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), scaling and root planing for 4 or more teeth per quadrant (D4341), and scaling and root planing for 1 to 3 teeth per quadrant (D4342) to be provided by a periodontist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the spinal canal and contents (72148) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the MRI of the spinal canal and contents. You say that this care is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to provide the medical care you need.

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 the magnetic resonance imaging (MRI) of the spinal canal and contents (72148) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0364) and three bone replacement grafts for ridge preservation (D7953 x3).

You asked the Plan to pre-approve the cone beam CT capture and interpretation and bone replacement grafts. You say that your provider advised that you need to have these procedures done. The Plan denied your request. The Plan says these services are not covered benefits.

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 a cone beam CT capture and interpretation (D0364) and three bone replacement grafts for ridge preservation (D7953 x3).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided form 
January 6, 2021, to January 11, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were held inpatient 
against your will. The Plan denied your request. The Plan says the claims were processed correctly and you are 
being charged the correct 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 $340 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from January 6, 2021, to January 11, 2021. Therefore, you are responsible to 
pay a $340 copayment for days 1-5 (January 6, 2021, to January 10, 2021). The total amount you owe is: $340 
(copayment) x 5 (inpatient days) = $1,700.  
 
You have been asked to pay the total copayment amount of $1,700 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided form January 6, 2021, to January 11, 2021.  
 
We note your complaint that you were admitted against your will. Your complaint is a grievance that must be 
answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services, 4 hours per day, 7 days per week.

You asked the Plan to pre-approve home health aide services. You say that your home health aide helps you with cooking, laundry, paying your rent, and when you have fainting spells. You also say that without your home health aide, your everyday life with be negatively affected. The Plan denied your request. The Plan says you do not qualify for the services as your clinical issues are not as severe as previously identified. The Plan also says that the services can be provided at a lower level of care.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home health aide services, 4 hours per day, 7 days per week.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for a specialist visit provided on April 12, 2021.

You asked the Plan to waive the deductible and coinsurance for a specialist visit. You say that you feel that the services should be considered preventative because of a family history of skin cancer. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $180 deductible. Your contract with the Plan also clearly says that after the $180 deductible has been met, enrollee's must pay 4% coinsurance for physician/practitioner services, including doctor's office visits. 

The record shows that you received specialist services on April 12, 2021. Specialist services are not including in annual wellness exams. Therefore, you are responsible to pay your share of the cost-sharing charges. The record shows that you had paid $0 toward the $180 deductible prior to receiving the services. Therefore, you are responsible to pay the $180 deductible. Now that the $180 deductible has been met, you must also pay 4% coinsurance on the difference between the allowed amount and the amount that applied toward the deductible.

$118.60 (allowed amount) - 103.52 (deductible) = $15.08 and 4% of that is $.60. The total amount you owe is: $180.60. 

The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $180 deductible which applies to physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time a specialist visit was received on April 12, 2021. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for a specialist visit provided on April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on April 12, 2021.
You asked the Plan to waive the copayment for lab services. You say that you have never paid for lab services in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $15 copayment for lab services. You received lab services at an outpatient hospital facility on April 12, 2021. Therefore, you are responsible to pay the $15 copayment. You have been asked to pay a $15 copayment for lab services. Lab services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 lab services provided on April 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services provided on March 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for mental health services. You say that you did not know that prior authorization was required because you were always paid in the past. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 mental health services provided on March 29, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says rules for SNF care have 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 the beneficiary is a 70-year-old male with left 
hip fracture and arthroplasty with cellulitis. While there are identifiable skilled therapy service needs, there are 
no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or 
therapy services on a daily basis. In conclusion, this beneficiary does 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 admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that this doctor comes highly recommended. 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 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 specialist services 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 Euflexxa injections.

You asked the Plan to pre-approve Euflexxa injections. You say that you need this because your knees are in pain and causes you to walk slow. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Euflexxa injections are only covered for certain indications. 

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 Euflexxa injections. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have arthritis and pain in both of your knees. There is no provided imaging studies, no documentation of any response to conservative therapies such as medication or physical therapy/exercise program, and no documentation of previous corticosteroid injections. There is no documentation that you have a diagnosis/condition that meets criteria for the requested 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 Euflexxa injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography (93306).

You asked the Plan to pre-approve a transthoracic echocardiography. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the enrollee's condition does not support the request for this procedure at this time.

The Plan follows Medicare rules. Medicare rules say that there are some indications for an echocardiogram to be performed more than once a year on patients who have congestive heart failure. 

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 transthoracic echocardiography. Our reviewer says that this request is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 56-year-old woman with ischemic cardiomyopathy on guideline directed medical therapy. Although there are indications for echocardiograms done more than annually on patients with congestive heart failure, this patient has stable clinical signs and symptoms. The medical regimen has remained stable and there have been no intercurrent procedures or cardiovascular events. In the absence of changes in clinical symptoms or signs, therapy, or other cardiac events, the recommended echocardiogram would not be considered medically necessary 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 transthoracic echocardiography have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiography (93306).