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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, like home with outpatient therapy.
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 Guillain-Barre syndrome and is living at home receiving home health services. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the mental health assessment (H0031) rendered by the OON
provider on February 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the mental health assessment (H0031) rendered by the OON provider on February 15,
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that if this doesn't get approved, you can't get to your appointments. The Plan denied your request. The Plan says all of the trips have been used.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 40 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bioimpedance spectroscopy (BIS) extracellular fluid analysis.
You asked the Plan to pre-approve BIS extracellular fluid analysis. You say that there is significant recent research showing that bioimpedance devices are supported by current medical literature. You say that the care being requested is medically necessary. The Plan denied your request. The Plan says the requested service is considered experimental and investigational. The Plan says that this procedure has not been identified as widely used and generally accepted for the proposed use.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 BIS extracellular fluid analysis. Our reviewer says that BIS extracellular fluid analysis is not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has had a primary excision and sentinel node dissection followed by radiation. The provided records indicate no evidence of lymphedema.
The provided medical records are insufficient to determine the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. There is insufficient literature to establish the requested test as safe and effective, as defined by Medicare rules, for the enrollee's specific clinical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of BIS extracellular fluid analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve Bioimpedance spectroscopy (BIS) extracellular fluid analysis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an infraumbilical panniculectomy and lipectomy.

You asked the Plan to pre-approve the requested services. You say that you are unable to do much because of your skin. The Plan denied your request. The Plan says cosmetic procedures are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 requested services. Our physician reviewer found that in this case, the record indicates you have excessive skin after weight loss over a ten-month period. The record does not indicate that you have intertrigo unresponsive to conservative management. The provided records do not support the medical necessity and reasonableness of the requested service for your condition.

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an infraumbilical panniculectomy and lipectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and three additional intraoral periapical x-rays (D0230 x3) provided on December 29, 2020.
You asked the Plan to pay for the intraoral periapical x-rays. You say that you told the provider you did not want x-rays unless they were covered. The Plan denied your request. The Plan says these services exceed the allowed frequency limitation for the time period.
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, you are limited to six periapical x-rays every two calendar years. The record shows that you received a first intraoral periapical x-ray (D0220) on February 12, 2019, another first intraoral periapical x-ray (D0220) and an additional intraoral periapical x-ray (D0230) on October 3, 2019, a first intraoral periapical x-ray (D0220) on October 31, 2019, and a first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) on December 29, 2020 and your periapical x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and three additional intraoral periapical x-rays (D0230 x3) provided on December 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for your routine transportation.
You asked the Plan to pre-approve additional miles. You say that you do not have the money to pay for gas. The Plan denied your request. The Plan says your benefit only allows 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Transportation over 50 miles was requested. We looked at your request, the records in the case file, and the rules. Your plan only covers transportation for up to 50 miles per one-way trip. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional mileage for your routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation inpatient mental health care from September 16, 2021, forward.

You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our physician reviewer found you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 16, 2021, forward, and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety.

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 mental health care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continuation inpatient mental health care from September 16, 2021, forward.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that therapy the enrollee needs can be given with home health 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
March 26, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you received the Moderna vaccine
and got sick, so you had to go to the ER. You say that the copayment should be waived because this was
related to the Coronavirus (COVID-19). The Plan denied your request. The Plan says you were charged this
copayment correctly because this charge was not related to testing or treatment for COVID-19.

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 $90
copayment for emergency room visits.

You have been asked to pay a $90 copayment for the ER visit. According to your Evidence of Coverage, the
copayment for COVID-19 treatment is only waived for testing or if you have a confirmed diagnosis of COVID-
19. The ER services you received were not related to COVID-19 testing and you did not have a confirmed
diagnosis of COVID-19. There is no provision in your contract for a waiver of the copayment for services
related to a reaction you may have to the vaccine. 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 emergency room (ER) visit you had on March 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy (90832) provided on January 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that your physician provided medically necessary services to the enrollee in good faith and the rendered services meet professionally recognized standards of healthcare. The Plan denied your request. The Plan says there was no documented contact with the attending/primary care physician. There is no referring physician listed on the claim.
Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can receive your care from either a network provider or an out-of-network provider. The requested provider in this case is not a network provider with the Plan. The claim does not include a referring provider and there is also no indication in the medical records that the provider reached out to the enrollee's primary care physician. 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 the individual psychotherapy (90832) provided on January 29, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for advanced care planning (99497), group diabetes training (G0109), pharmacologic management (90863), pain severity quantification (1125F), and medication list documentation (1159F) provided on July 15, 2020.
You asked the Plan to pay for advanced care planning, group diabetes training, pharmacologic management, pain severity quantification, and medication list documentation. You say that these services are supported in the records. The Plan denied your request. The Plan says these services cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that a status code of I indicates that a code is not valid for Medicare purposes. A status code of M indicates measurement codes, used for reporting purposes only. In this case, the CPT Code Manual definition of code 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. The definition of G0109 is diabetes outpatient self-management training services, group session (2 or more), per 30 minutes. Codes 90863 and 1159F have status codes of I, and code 1125F has a status code of M. We find that CPT codes 99497, G0109, 90863, 1125F, and 1159F are not supported in the medical record. Specifically, there is no documentation of advanced care planning in the medical records. The records also indicate that the diabetes training provided was performed individually rather than in a group. Codes 90863, 1125F, and 1159F are not payable due to their status codes. Based on this information, we decided that Medicare rules for coverage of advanced care planning, group diabetes training, pharmacologic management, pain severity quantification, and medication list documentation have not been met. Therefore, we decided that the Plan does not have to pay for advanced care planning (99497), group diabetes training (G0109), pharmacologic management (90863), pain severity quantification (1125F), and medication list documentation (1159F) provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5257) provided on April 2, 2021.
You asked the Plan to pay for hearing aids. You say that you were told that there were no hearing aid providers in your area. You also say that you were not told to contact a Plan provider. The Plan denied your request. The Plan says you purchased hearing aids by an out-of-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider. We looked at the file, and the Plan's rules. The records show that you did not receive hearing aids from the Plan's specific required provider. The Plan has network providers available who can provide the items/services at issue in this appeal. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5257) provided on April 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.
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 does not require the intensity of services provided at the IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. Care needs can be met at a lower level of care, such as skilled nursing facility, home
health, or outpatient therapy. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 enrollee does not need physical therapy but requires complex medical nursing care. The Plan denied your request. The Plan says the stay 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 5, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not payable.

The Plan must follow Medicare rules. Medicare rules say that effective for claims with dates of service July 1, 2007 and after, the non-Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. This integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital claims, through a single integrated OCE. 

We looked at the file and Medicare rules. in this case, code 93925 is assigned a status indicator of "M", which produces edit 72, indicating that this service is not billable to the Medicare Administrative Contractor (MAC). As such, the outpatient hospital claim is not payable as billed. 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 February 5, 2021.