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

We decided that the Plan does not have to pre-approve rhizotomy/radiofrequency (RF) ablation (64635 and 64636).
You asked the Plan to pre-approve rhizotomy/RF ablation. You say that your doctors believe this would give you several months of pain relief. The Plan denied your request. The Plan says you did not have sufficient pain reduction with the previous rhizotomy.
The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint RF ablation at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of 50% improvement in pain for at least six (6) months. 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 rhizotomy/RF ablation. Our reviewer says that the requested rhizotomy is not medically necessary. Our physician reviewer found the medical records do not show adequate pain relief with previous injection 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 rhizotomy/RF ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve rhizotomy/radiofrequency (RF) ablation (64635 and 64636).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says that you do not meet criteria for coverage of an acute inpatient rehabilitation facility admission.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 acute inpatient rehabilitation facility care. Our reviewer says that the requested inpatient rehabilitation facility care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that your medical conditions appear stable. There are no wound care needs. There are no unaddressed medical issues. You are currently in an outpatient setting and do not require an acute hospital level of care. You require physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, an intensive rehabilitation therapy program would not significantly impact your condition differently compared to therapy provided at a less intense level. Your care can be appropriately provided though ongoing home-basedcare or at a skilled nursing facility level.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient rehabilitation facility care have not been met.Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.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.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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care on 3/3/20 for shortness of breath with diagnosis of chronic obstructive pulmonary disease, pneumonia and acute on chronic hypercapnic respiratory failure treated with IV antibiotics, steroids and BiPAP. From a nursing perspective, the enrollee received oral and inhaled medications and insulin. The enrollee had stable vital signs. He used oxygen via nasal cannula. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a minimal to moderate assist level with functional mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician consultation to be provided by an out of network (OON) provider.You asked the Plan to pre-approve physician consultation. You say that you would like to see a doctor about having hernia surgery.The Plan denied your request. The Plan says there are in-network providers available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve physician consultation to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem tablets.
You asked the Plan to pre-approve Zolpidem tablets. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zolpidem tablets.
Benefits for Zolpidem tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology servicesto be provided by an out of network (OON) provider.You asked the Plan to pre-approve ophthalmology services. You say that you have been seeing this doctor for 30 years.The Plan denied your request. The Plan says there are multiple in network providers available for these services. The Plan says that you can be treated by any ophthalmologist at in network medical system.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.You asked the Plan to pre-approve the referral. You say that this is medically necessary.The Plan denied your request. The Plan says medically necessary care is available in-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra for the enrollee.
You asked the Plan to pre-approve Actemra. You say that this is medically necessary. The Plan denied your
request. The Plan says that self-administered drugs are not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Actemra for the enrollee.
Benefits for Actemra may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee would benefit from close physician management and three daily hours of therapy.The Plan denied your request. The Plan says there is no evidence that the IRF level of care is medically necessary in this case.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 enrollee underwent spinal surgery on 2/21/2020. She was independent in ambulation with a walker and independent in ADLs in the Fall season but began declining in January 2020. She was at a nursing home prior to her surgery. She did not improve at the nursing home and is fearful of falling. She was discharged home after surgery with home health and was supervision with bed mobility, grooming, eating, mod assist bathing, max assist toileting, min assist UE dressing and max assist LE dressing.The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found in the case of this enrollee, complicated sigmoid stricture warranted diverting loop colostomy, NG tube foods and TPN, IV antibiotics, and monitoring in an acute care facility, which was appropriate. The most current notes describe significant acute care needs including solving the cause of no ostomy output, IV antibiotics, and monitoring until fever resolves. The enrollee is not stable for discharge at this time. Based on the clinical progression, continued acute care services at the current facility would be most appropriate. The services proposed at the LTACH are already being received and covered at the current facility and transfer would not provide any improvement in care. Therefore, this request for LTACH services will be considered not medically necessary. 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 long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility care beyond March 11, 2020.You asked the Plan to pre-approve the continued SNF care. You say that the enrollee needs ongoing care in this setting.The Plan denied your request. The Plan says the enrollee no longer needs daily skilled services. His needs are mainly custodial in nature.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.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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found This patient 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 only in a SNF. The patient does not have complex wound care or other SNF level skilled nursing need. This patient's functional status does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The patient does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this patient 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 the continued SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility care beyond March 11, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued palliative home health services for the enrollee.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says current needs do not appear to be skilled in nature.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 the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does not have a new feeding tube or new tracheostomy tube. There are no complex wounds. The enrollee's needs do not require ongoing professional skilled nursing services. The records reveal the enrollee had prior therapy and was able to complete a home exercise program. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee.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 continued palliative home health services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral exam (D0150) cleaning (D1110) bitewing x-rays (D0274) intraoral first x-rays (D0220) intraoral additional x-rays (D0230) provided February 6, 2019.You asked the Plan to pay forthe dental services. You say that you are requesting an appeal because the dental procedures denied are covered expenses.The Plan denied your request. The Plan says this plan was not effective until March 1, 2019. Services received prior to the effective date will not be covered by the plan.Medicare generally does not cover dental services. The Plan follows the same rule.This plan was not effective until March 1, 2019. Based on this information, we decided that the Plan does not have to pay for oral exam (D0150) cleaning (D1110) bitewing x-rays (D0274) intraoral first x-rays (D0220) intraoral additional x-rays (D0230) provided February 6, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehydrocodone/acetaminophen tablets.You asked the Plan to pre-approvehydrocodone/acetaminophen tablets. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says hydrocodone/acetaminophen tablets are not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvehydrocodone/acetaminophen tablets.Benefits for hydrocodone/acetaminophen tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 1,
2019.
You asked the Plan to waive the copayment for the office visit. You say that this was a follow up. You say that
you should be reimbursed. The Plan denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay $50 for
each Medicare-covered specialist office visit.
You have been asked to pay a $50 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the
contract which indicates a copayment would be waived for services performed as a follow-up. 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 office visit provided on November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea compression garment identified with code A6549.You asked the Plan to pre-approvethe compression garment. You say that because of a medical condition the enrollee needs a compression garment.The Plan denied your request. The Plan says the enrollee's condition is not a covered reason.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549are noncovered because they do not meet the statutory definition of a surgical dressing. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvea compression garment identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99220) provided on June 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services can only be billed by the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that payment for an initial observation care code is for all the care rendered by the ordering physician on the date the patient's observation services began. We looked at the file and Medicare rules. The initial observation care in question was billed by a physician who was not the ordering physician. This code was billed on a separate claim by the ordering physician, and only those services are payable under 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 services (99220) provided on June 5, 2019.