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

 We decided that the Plan does not have to pre-approve additional PT visits.  You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is 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 additional PT 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 the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior extensive therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. The provider notes that full recovery of drop foot has not been achieved, however you have had extensive therapy to learn compensation, safety, and a home exercise program. Neural recovery of the drop foot is not dependent on additional physical therapy. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve office visit. You say that after the enrollee's prior physician retired it was hard to find an endocrinologist who had the ability to work with her, but she has been able to build a relationship with this provider. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network specialist.  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. The record does not show that the enrollee is receiving active, ongoing treatment, so no continuity of care issue has been identified in this case. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional hours of home health aide (HHA) services (G0156).  You asked the Plan to pre-approve the additional hours of HHA services. The Plan denied your request. The Plan says you no longer qualify for 84 HHA hours per week due to the excessive number of hours being requested.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 the additional hours of HHA services. Our reviewer says that continual supervision, during the day or night, is custodial and not medically necessary, reasonable or coverable. Our physician reviewer found you have been receiving personal care services at home for years. Our reviewer found that there is no evidence of a new or acute medical issue warranting medically necessary care. Our physician reviewer also found that while you certainly need assistance in completing activities of daily living, such assistance is intermittent.  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 additional hours of HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional hours of home health aide (HHA) services (G0156).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation that the enrollee will benefit from and improve with LTACH management with vent dependence and persist encephalopathy, remaining minimally responsive.  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 indicating medical necessity for 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 he is 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the immediate lower denture (D5140) provided on July 13, 2021.  You asked the Plan to pay for the dental item. You say that your $2,000 has not been met. The Plan denied your request. The Plan says there is a $2,000 allowance per year. The Plan also says that the allowance has been exhausted.  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 and the denture is listed as covered, the annual allowance has been exhausted. The record shows that the Plan paid $154 for dental services received on March 3, 2021, $244 for dental services received on May 11, 2021, $244 for dental services received on June 2, 2021, and $1,358 for dental services received on July 13, 2021. $154 + $244 + $244 + $1,358 = $2,000. Therefore, we decided that the Plan does not have to pay for the immediate lower denture (D5140) provided on July 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Cochlear device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is needed to improve hearing. The Plan denied your request. The Plan says there is no evidence of bilateral moderate to profound hearing loss.  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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have a diagnosis of bilateral moderate to profound sensorineural hearing impairment with limited benefit from appropriate hearing or vibrotactile aids. The enrollee's hearing loss is unilateral.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Cochlear device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on April 26, 2021.

You asked the Plan to pay in full for the complete maxillary denture and complete mandibular denture. You say that no one told you about any copays you would be responsible for. The Plan denied your request. The Plan says the annual limit allowed by your dental plan for the 2021 benefit year has been paid.

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 Plan offers up to $1,000 every year for non-Medicare covered preventive and comprehensive dental services combined.

The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while processing this claim for the April 26, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay in full for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on
April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you are on oxygen and have been in the hospital since November 2, 2021. The Plan denied your request. The Plan says IRF care 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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for respiratory failure and pneumonia. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the telephone evaluation and management service (99442) provided on March 17, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for evaluation and management service. You say that telehealth visits are being utilized by providers during the COVID pandemic to treat patients much the same as face to face visits. Please reconsider this claim for payment. The Plan denied your request. The Plan says 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 the telephone evaluation and management service (99442) provided on March 17, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the computer assistance (navigational) for the procedure performed on July 13, 2021.

You asked the Plan to pay for the computer assistance. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pay for the computer assistance. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the operative report dated July 14, 2021, supports that neuronavigation was used during the surgical procedure, and was medically reasonable and necessary for the enrollee in this case. Frameless stereotaxy is a well-established practice, and has been shown to be a safe, accurate, and effective technique for functional stereotactic approaches. 

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 computer assistance have been met. Therefore, we decided that the Plan has to pay for the computer assistance (navigational) for the procedure performed on July 13, 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a PET scan.  You asked the Plan to pre-approve a PET scan. You say that you would like to have a PET scan to ease your mind. The Plan denied your request. The Plan says a PET scan is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 a PET scan. Our reviewer says that a PET scan is not medically necessary. Our physician reviewer found this case, the record indicates that you had breast cancer in 1998. The record indicates that you do not have breast cancer at this time, and you are not receiving active treatment that may be altered by the results of the requested test. The elements of the coverage criteria are not satisfied.  The requested service cannot be recommended.         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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a physical therapy evaluation (97162) provided on April 23, 2021.  You asked the Plan to waive the copayment for a physical therapy evaluation. You say that you spoke with the Plan's eligibility department and you were told that a pre-certification request was not required for the enrollee. The Plan denied your request. The Plan says the copayment the enrollee is being charged is correct.  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 a $30 copayment for outpatient rehabilitation services.        The enrollee has been asked to pay a $30 copayment for a physical therapy evaluation. The EOC confirms that $30 is the required copayment for this service. The records confirm that the provider was paid $139.14 for this service. A physical therapy evaluation falls within the outpatient rehabilitation services 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 copayment for a physical therapy evaluation (97162) provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine eye exam (92004), fundus photography (92250), and eyeglasses (V2100, V2783, V2744, V2750) provided on March 8, 2021.  You asked the Plan to pay for the vision services. You say that you were told this provider accepts your insurance and is in-network. The Plan denied your request. The Plan says fundus photography is not covered by your supplemental vision benefit. The provider in question is also not part of the Plan's routine vision network. Supplemental vision services received out-of-network are not covered.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from a provider within the Plan's routine vision network.  We looked at the file and the Plan's rules. Fundus photography is not a covered service under the Plan's vision benefit. In addition, the provider in this case does not participate with the Plan's specified routine vision network. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the routine eye exam (92004), fundus photography (92250), and eyeglasses (V2100, V2783, V2744, V2750) provided on March 8, 2021.   Your complaint about potential misinformation or possible confusion between the routine vision network and medical network 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services provided from July 4, 2020, to  July 8, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis codes are not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with diagnosis codes N17.0 and E43. 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. Our reviewer says that the use of diagnosis codes N17.9 and E43 is not supported by the records provided. Our physician reviewer found that the documentation was unclear regarding a diagnosis of acute kidney failure (injury) (AKI) and inconsistent regarding a diagnosis of malnutrition. Even though AKI was documented throughout the record and malnutrition is noted in an addendum, supporting documentation was not found within the submitted medical record.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from July 4, 2020, to July 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 8, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 8, 2020.