Persius/hicric huggingface dataset:
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 enrollee would benefit from inpatient rehab. The
appellant says that the enrollee lives alone and that they are trying to get him to his prior state of health. The
Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan
says that the enrollee could receive care 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 above.
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 a COVID-19 infection. The enrollee's medical conditions are stable. There are no medical
needs requiring inpatient admission. 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 medical record documents a need for physical and
occupational therapy, it does not document 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not
require supervision of a rehab doctor, or aggressive therapies by an intensive team.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 physician reviewer found
that you were admitted to the acute hospital for congestive heart failure exacerbation. You were also treated
non-operatively for a fractured humerus from a fall prior to hospitalization. Your medical conditions are stable.
The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that you will
be able to fully participate in and benefit from the intensive rehabilitation therapy program. While the medical
record documents a need for physical and occupational therapy, it does not document a need for an intensive
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from January 20, 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 based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 20, 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 of inpatient mental health care from January 20, 2021, forward.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that the enrollee has not recovered. The Plan
denied your request. The Plan says the enrollee does not require skilled nursing or therapy services at a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
Continued SNF services beyond January 21, 2021, were requested. 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 continued services. Our physician reviewer found that from a nursing
perspective, the enrollee received oral medications, had stable vital signs, and was treated for pain with effect.
There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a contact
guard to moderate assist level with functional mobility. She required varying assist with activities of daily
living. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or
therapy services on a daily basis. She does not meet severity of illness or intensity of service criteria for an
inpatient basis in a SNF 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 continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan does not have to pay for physician services billed to the enrollee on December 5, 2019.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan states that Maximus has issued an overturn decision stating that the Plan must pay for epigastric hernia repair (49572) provided on December 5, 2019 for the above-mentioned claim. The Plan determined that this claim denied because this service was included as part of the global surgical package of the initial surgical procedure. The Plan states this service was previously paid under a separate claim. The Plan states that the NPI website shows you are listed under two separate names. The claims show the same NPI number was submitted on both claims. The Plan states since they had already paid for this service during the post-operative period of the surgery on October 23, 2019, the claim for December 5, 2019 was denied.  

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case there is a question as to why the same provider is billing the service twice under an identical NPI number. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for physician services billed to the enrollee under claim on December 5, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to provide coverage for a positron emission tomography (PET) scan for the enrollee.

You asked the Plan to provide coverage for a PET scan. You say that a PET scan is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Weoverturned the Plans denial. The Plan requested a reopen and stated that We did not apply the correct criteria.

Our Medial Director looked at the case file the reopen request. At issue is coverage for a PET scan.
The Physician Reviewer determined that an FDG PET is a reasonable adjunct to the diagnosis of dementia and was medically reasonable and necessary for the enrollee in this case.  The Plan requested a reopen stating the NCD does not include the metabolic PET scan as a routine part of the evaluation of all dementia. The medical records show the enrollee is an 81-year-old man with a diagnosis of Other amnesia. The enrollee has a history of diabetes and concussions and was evaluated on July 24, 2020 for a history of more than four years of word finding difficulties. The enrollee met criteria for mild cognitive impairment. An MRI of the brain revealed mild volume loss without regional predominant atrophy. Our Medical Director determined the plan is correct in this case. The documentation in the case file does not support that the enrollee meets criteria for both Alzheimer's disease and frontotemporal dementia. 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 provide coverage for a positron emission tomography (PET) scan for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable


 
We decided that the Plan does not have to pay for physician's services provided on September 18, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physicians services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on September 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF 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 IRF admission is covered only when it is medically reasonable and necessary as described above.

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 based on the documentation provided, the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on August 4, 2020.You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on August 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan (74178) on October 02, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you were misdiagnosed; therefore you shouldn't have to pay. The Plan denied your request. The Plan says there is a $275 copayment for each advanced imaging service.
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 $275 copayment for Outpatient diagnostic testing. You have been asked to pay a $275 copayment for a CT scan. The CT scan falls within the Outpatient diagnostic testing 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 CT scan (74178) on October 02, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approveSynvisc.You asked the Plan to pre-approveSynvisc. You say that the injection is necessary for relief in the left knee.The Plan denied your request. The Plan says the enrollee must have tried and failed Monovisc and Orthovisc.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Synvisc. Our reviewer says that the enrollee has tried and failed Monovisc and Orthovisc.Our physician reviewer found that the documentation does not support that Monovisc and Orthovisc would be less effective or have adverse effects. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says you do
not need skilled medical care.
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. Custodial care is not covered.
We looked at the file, and Medicare rules. Bathing and taking charge of medicine that usually can be selfadministered are custodial care services. Based on this information, we decided that Medicare rules for
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve home health
skilled nursing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953 x 2), and the
medicaments (D9612) provided on July 14, 2020.
You asked the Plan to pay for the bone replacement graft and medicaments. You say that all dental procedures
are traumatic for you. You say that your policy misled you to think that you would be covered. You also say
that the documentation sent in by your provider clearly shows that you needed the services. The Plan denied
your request. The Plan says bone replacement graft is not listed as a covered service. The Plan says that
medicaments are not listed as a covered service.
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 bone
replacement graft (D7953 x 2), and the medicaments (D9612) provided on July 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe laboratory work provided from October 9, 2020, to October 13, 2020.You asked the Plan to waive the deductible forthe laboratory work. You say that you have never been charged for laboratory work. You say your literature from the Plan says you have a $0 copayment.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. Your contract with the Plan says that there is a$250 deductible that applies towards laboratory work. The laboratory work you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies towards laboratory tests. This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received on October 9, 2020 to October 13, 2020.Therefore, we decided that the Plan does not have to waive the deductible forthe laboratory work provided from October 9, 2020, to October 13, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care rendered from August 17, 2020 to
September 3, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan
denied your request. The Plan says that the services were not medically necessary.
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 services were medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital with infection of surgical site. She underwent excisional debridement and a repeat resection of the
right forearm with wound vac placement. She underwent repeat incision and drainage with wound vac
placement on August 21, 2020. The records support that, at the time of inpatient admission, the admitting
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or
observation care) would span two midnights.
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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care rendered from August 17, 2020 to September 3, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet block injections (CPT Codes: 64495, 64493 and
64494).
You asked the Plan to pre-approve the services. You say that this will endanger your health because as of every
day that goes by the pain on your lower back gets worse. You state you can't even walk or stand because of the
pain. The Plan denied your request. The Plan says there was insufficient documentation to verify if you meet
Medicare criteria for the 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 the services. Our physician reviewer
found in this case, you have radiculopathy. The review has determined that the medical records provided do not
meet the requirements listed in the LCD for Medicare coverage.
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 pre-approve facet block injections (CPT Codes: 64495, 64493 and 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora shower chair provided by Conlin's Pharmacy, Inc.

You asked the Plan to pay fora shower chair. You say that this has a prescription from your doctor.The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pay fora shower chair provided by Conlin's Pharmacy, Inc.