Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 physical therapy visits (PT) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve 12 PT visits. You say that the services are necessary, and this provider is closest to you. The Plan denied your request. The Plan says services with and out-of-network provider are not covered.

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 12 physical therapy visits (PT) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  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 repeat facet joint injections (64494, 64493).  You asked the Plan to pre-approve the repeat facet joint injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  Medicare rules say that injections or medial branch blocks at the same level as a previously successful radiofrequency ablation procedure are not medically necessary.  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 repeat facet joint injections. Our reviewer says that the repeat injections are not medically necessary. Our physician reviewer found there is no indication to repeat diagnostic medial branch blocks when there has been successful radiofrequency ablation performed at the same level.  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 repeat facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat facet joint injections (64494, 64493).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve retainer crowns (D6750 x2), and pontic (D6240).  You asked the Plan to pre-approve retainer crowns, and pontic. You say that the services are necessary. The Plan denied your request. The Plan says the services at issue 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 retainer crowns (D6750 x2), and pontic (D6240).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the vision specialist office visit provided on November 12, 2020.  You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have to pay another copay for a duplicate eye exam. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for each specialist doctor visit.   You have been asked to pay a $30 copayment for the specialist office visit. The record shows the exam you received was more complex than a routine eye exam. The specialist office visit falls within the Doctor 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 the vision specialist office visit provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the three labial veneers (D2962 x3) provided on July 8, 2021.  You asked the Plan to pay for the labial veneers. You say that you believe you should be reimbursed for these services. The Plan denied your request. The Plan says labial veneer is not a covered expense under your dental plan.  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 pay for the three labial veneers (D2962 x3) provided on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 2, 2021.  You asked the Plan to pay for the panoramic x-ray. You say that this x-ray was reasonable and necessary. The Plan denied your request. The Plan says this service exceeds the benefit limit.  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, panoramic or full mouth x-rays are payable once in any two-year period. The record shows that you received a full series of x-rays on September 10, 2020 and your panoramic or full mouth x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on June 9, 2021.  You asked the Plan to pay for the genetic testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.  We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the physician services provided on June 5, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the processing of this claim was correct.

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. 

We looked at the file and the rules. In this case, there is no explanation of benefits, no claim, or no details of when the claim was received. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the physician services provided on June 5, 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve L4-L5 and L5-S1 facet joint injections.  You asked the Plan to pre-approve facet joint injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that facet joint 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 facet joint injections. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee a history of chronic back pain with sciatica due to degenerative disc disease. On exam there is tenderness with palpation over the lower lumbar facet joints at L4/5 and L5/S1 levels. In addition, imaging shows scattered degenerative changes to the lumbar spine. The enrollee has been treated with medical therapy including opiates.     The coverage criteria states that the primary indication of a diagnostic facet joint procedure is to diagnose whether the patient has facet syndrome. Intra-articular (IA) facet block(s) are considered reasonable and necessary as a diagnostic test only if medial branch blocks (MBBs) cannot be performed due to specific documented anatomic restrictions or there is an indication to proceed with therapeutic intraarticular injections. These restrictions must be clearly documented in the medical record and made available upon request. Therefore, the enrollee does not meet 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve L4-L5 and L5-S1 facet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 15, 2021, to April 16, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically appropriate. The Plan denied your request. The Plan says the provided care is consistent with observation level of care.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided documentation indicates that the enrollee was stable enough to be discharged. The reviewer found that there was no formal need for hospitalization for the enrollee. Therefore, the reviewer found that the criteria for inpatient care was not met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Specifically, the file shows that there was no formal need for hospitalization, as such, there is no expectation that the enrollee's care would span 2 midnights. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided April 15, 2021, to April 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from March 19, 2020, to April 3, 2020.  You asked the Plan to pay for SNF services. You say that all medications show an active disease process. The Plan denied your request. The Plan says the documentation does not support the NTA component for malnutrition.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We asked our coder 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 SNF services. Our reviewer found that the enrollee suffered an unspecified fracture of his left wrist/hand in a fall. The enrollee had a stage 1 wound on his sacrum, and a stage 2 wound on his right buttock. It is noted that the enrollee was at risk for malnutrition. A daily multivitamin was prescribed. The enrollee was provided with a fortified shake daily. The documentation is insufficient to support the inclusion of malnutrition/risk of malnutrition as an active diagnosis for the SNF stay at issue. The available clinical documentation in the case file does not include an active diagnosis of malnutrition or risk of malnutrition, signed and dated by the physician.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from March 19, 2020, to April 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the anesthesia services provided on May 18, 2021.  You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.  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 documentation provided shows that the case file submitted to us by the Plan was largely incomplete. The case file does not contain a claim denying payment for these services. The Plan provided no evidence based on Medicare criteria as to the reasoning a claim denied for payment. We find that the Plan has not shown that its decision to deny payment for these services is correct or justified based on Medicare rules. Therefore, we decided that the Plan has to pay for the anesthesia services provided on May 18, 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuation of SNF services provided from March 5, 2021, through March 19, 2021.  You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF services 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 pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found from a nursing perspective the enrollee received oral medications. The enrollee had stable vital signs. The enrollee had uncomplicated wound care to multiple sites. Regarding rehabilitation services, the enrollee received physical therapy (PT). By the dates in question, the enrollee was at dependent level or mechanical lift for transfers, and he was non-ambulatory. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee 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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from March 5, 2021, through March 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the anesthesia services provided on May 18, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the processing of this claim was correct.

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. 

We looked at the file and the rules. This case, being only 9 pages, is largely incomplete. The Plan has failed to fully explain their rationale for denying the services at issue. There is no explanation of benefits, or notice of denial of payment, no remittance, no Medicare rules, or any other notification/documentation to explain the denial. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the anesthesia services provided on May 18, 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.