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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you have already been in the hospital for 5
weeks and the more you continue to stay at the hospital the weaker you are going to get. You say that the
physical therapy provided at the hospital has not been enough to help with regaining mobility and you are not
ready for discharge home. The Plan denied your request. The Plan says the guidelines for coverage of 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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely
and effectively provide medically necessary and reasonable treatment in a SNF. The documentation indicates
the enrollee is still requiring acute care medical management to ensure the enrollee is stable when the
dobutamine drop is discontinued during weaning. The enrollee's functional level does not require skilled
therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and
effectively provide medically necessary and reasonable treatment in a SNF. He is ambulating and transferring
standby assist. The enrollee does not require skilled nursing or skilled therapy services (or a combination of
these services) on a "daily basis" in a SNF. As a practical matter the enrollee does not require the necessary
services on 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic continuous glucose monitor (CGM) related supplies.

You asked the Plan to pre-approve CGM related supplies. You say that the medical records provided support the need for the requested item. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. The records show that the enrollee is on two insulin injections a day. Based on this information, we decided that Medicare rules for coverage of CGM related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic continuous glucose monitor (CGM) related supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental procedure with anesthesia to be provided at an
outpatient surgical center or hospital.
You asked the Plan to pre-approve the dental procedure at an outpatient surgical center or hospital.. You say
that due to medical conditions it's medically necessary for anesthesia to be used at a hospital instead of using
nitrous oxide at a dentist's office. The Plan denied your request. The Plan says surgical center or hospital fees
associated with dental procedures are not a Medicare covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Medicare has only allowed coverage of inpatient services related to
dental care and does not provide this coverage in the outpatient setting. Contact the provider to request this
procedure as an inpatient service. Therefore, we decided that the Plan does not have to pre-approve a dental
procedure with anesthesia to be provided at an outpatient surgical center or hospital.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee was admitted to the SNF on two
different occasions for unrelated events. You say that, because of this, they should each qualify for separate
insurance coverage. The Plan denied your request. The Plan says the enrollee has met the plan limits for SNF
care.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from September 9,
2021 - December 21, 2021. The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (procedure codes A0425, A0428)
provided to the enrollee on February 14, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says a sequela (7th character "S") code cannot be reported as the first-listed/primary diagnosis on a
claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that procedure codes A0425 and A0428 are not supported in the medical record. Specifically, the
primary diagnosis in this case was a S code, which indicates that it is a diagnosis received from an injury. The
appropriate primary diagnosis code would one based on the original injury, not a manifestation of that injury.
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 ambulance services (procedure codes A0425,
A0428) provided to the enrollee on February 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient rehabilitation admission and
services provided March 27, 2021, to April 3, 2021, by an OON provider.

You asked the Plan to waive the coinsurance for the inpatient rehabilitation admission and services. You say
that you believed the enrollee's coinsurance would be waived since it was related to COVID. The Plan denied
your request. The Plan says the Plan's coronavirus (COVID) waiver ended on February 15, 2021, and did not
apply to the enrollee's inpatient stay. The cost-sharing has applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay 30% coinsurance for each Medicare-covered inpatient hospital stay when provided OON.

The enrollee has been asked to pay a total of $4,353.30 ($14,510.99 total approved amount x 30% coinsurance
= $4,353) for the inpatient rehabilitation admission and services provided by an OON provider. The inpatient
rehabilitation admission and services falls within the Inpatient hospital care benefit category. This means that
the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan
does not have to waive the coinsurance for the inpatient rehabilitation admission and services provided March
27, 2021, to April 3, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver) (CPT code 88312) provided to the enrollee on July 20, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says there is insufficient diagnosis and service information in the available patient data to explain and support a special stain (code 88312) for nail pathologies.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

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 the service. Our reviewer found the provider reported a group I special stain for microorganisms along with other items or services on the claim. Per the Centers for Medicare & Medicaid Services (CMS), the treating physician must order all laboratory and diagnostic tests for a specified medical diagnosis, and the results of the laboratory and diagnostic tests must be utilized in the treatment of the enrollee's specified medical problem. To meet this standard, the medical record documentation must include:- Clinical evidence of mycosis of the toenail,- AND- the enrollee has marked limitation of ambulation, pain, or secondary infection resulting from thickening and dystrophy of the infected toenail plate (CMS). The claim data and documentation did not indicate the presence of signs, symptoms, complaints, or personal history of disease or injury as required for special stains. The claim data and documentation did not indicate the special stain was utilized for the diagnosis or treatment of the enrollee's illness. The review has determined that the medical records provided did not meet the requirements listed in the LCD for Medicare coverage. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver) (CPT code 88312) provided to the enrollee on July 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.


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 your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting.

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 your 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the replacement of gastrostomy tube
procedure provided on June 11, 2021.
You asked the Plan to waive the copayment for the replacement of gastrostomy tube procedure. You say that
you should not be responsible for the copayment. You say no surgery was performed. The Plan denied your
request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450
copayment for an in-network outpatient hospital.
You have been asked to pay a $450 copayment for the replacement of gastrostomy tube procedure. The
replacement of gastrostomy tube procedure falls within the "Outpatient surgery, including services provided at
hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the procedure
is considered a surgical procedure. 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 replacement of
gastrostomy tube procedure provided on June 11, 2021.
Your complaint about the provider mistakes is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from January 31, 2022,
forward.
You asked the Plan to pre-approve SNF 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 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 there is no documentation that the patient
requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional
nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do
require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are
required to safely and effectively provide medically necessary and reasonable treatment. However, your
multiple refusals to participate with therapy have led to services being discontinued. Daily skilled services are
not required. You do not require the services on an inpatient basis, only in a SNF setting. Services in the long-
term care facility on a part time basis (as you will allow) appear appropriate in this case.
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 continuation of SNF care from January 31, 2022, forward.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional home health skilled nursing visits (G0299).

You asked the Plan to pre-approve home health skilled nursing services. You say that these additional home health services are medically reasonable and necessary. The Plan denied your request. The Plan says the criteria have not been met for the requested additional home health services.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health skilled nursing services. Our reviewer says that the requested home health skilled nursing services are not medically reasonable and necessary. Our physician reviewer found that you are a 65-year-old female with a history of chronic obstructive pulmonary disease (COPD). In this case, you do not have documented skilled nursing needs. As such, the requested, ongoing, home health skilled nursing services are not medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional home health skilled nursing visits (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and
management of an established patient (CPT code 99212GY) provided from September 21, 2021, through
September 23, 2021.
You asked the Plan to pay for the services. You say that you do not agree with being charged for an office visit.
The Plan denied your request. The Plan says they will cover only manual manipulation of the spine to correct
subluxation.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Medicare and the health plan
will only cover manual manipulation of the spine to correct subluxation.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for the office or other outpatient visit for the evaluation and management of an established patient
(CPT code 99212GY) provided from September 21, 2021, through September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted case management (T1017) provided on August 31, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for targeted case management. You say that the medical records provided support the necessity of the services in dispute. 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 targeted case management (T1017) provided on August 31, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesiology and outpatient operating room charges provided on April 27, 2021.

You asked the Plan to pay for the outpatient hospital services. You say that this extraction was medically necessary. You say that you were advised your extraction would take place in an operating room due to your trismus. You say that you assumed this was medically necessary due to your previous cancer surgery which caused significant trismus. You also say that you feel the services should be covered. The Plan denied your request. The Plan says The Plan says that the outpatient hospital services are not covered.

The Plan must follow Medicare rules. Medicare rules say that when a patient is hospitalized for a dental procedure and the dentist's service is covered under Part B, the inpatient hospital services furnished are covered under Part A. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not been met. Specifically, the file does not show that you were inpatient when you received these services. Therefore, we decided that the Plan does not have to pay for the anesthesiology and outpatient operating room charges provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99204) provided to the enrollee on
June 27, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the service is not covered 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 correct POS code -- regardless of where the face-to-face service occurs -- is that of the appropriate
inpatient POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital POS code (at a
minimum POS code 19 or 22, for outpatient services performed off campus or on campus) as discussed in the
Medicare Claims Processing Manual, section 10.5. Place of service 23 is not an appropriate place of service for
CPT code 99204 per this guideline. As a corrected claim has not been submitted with an updated place of
service, this claim is processed correctly. Based on this information, we decided that Medicare rules for
coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the
office visit (CPT code 99204) provided to the enrollee on June 27, 2021.