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 needs an IRF admission. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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 there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 one-way transportation trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motorized scooter.

You asked the Plan to pre-approve a motorized scooter. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested motorized scooter.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, your condition can be improved by a walker, cane or manual wheelchair and there is no documentation showing that you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a motorized scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a second unit of critical care service provided on August 10, 2020.

You asked the Plan to pay for critical care services (99291). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no additional documentation supporting additional services which were billed and remain denied.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

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 second unit of critical care service (99291). Our reviewer says that the documentation submitted was reviewed and does not meet criteria. Our physician reviewer found the documentation does not support billing CPT 99291 twice on the same date of service, and documentation does not support a separate service. Therefore, CPT 99291 would not be covered. 

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 second unit of critical care services (99291) have not been met. Therefore, we decided that the Plan does not have to pay for the second unit of critical care service provided on August 10, 2020.
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 IRF services are medically necessary to help
strengthen your walking, memory, and speech. The Plan denied your request. The Plan says you can safely
receive services needed in other settings such as a skilled nursing facility or home health services.

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 there are no complex nursing or rehabilitation needs. The patient does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. The patient does require physical and occupational therapy but there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care. There is not a reasonable expectation that this patient 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 continued mental health inpatient psychiatric services
from June 18, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric services from June 18, 2021, and beyond.
You say that the enrollee is gravely disabled and meets medical necessity for inpatient psychiatric treatment.
The Plan denied your request. The Plan says the enrollee does not have any acute symptoms that require 24-
hour inpatient care after June 17, 2021.
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 continued psychiatric services from
June 18, 2021, and beyond. Our reviewer says that the health plan's denial of continued inpatient psychiatric
services is appropriate. Our physician reviewer found this enrollee did not appear to require inpatient mental
health treatment beyond the date in question as she was not a danger to herself or others and did not have any
auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment
was taking place beyond the date in question. It did not appear that the services were reasonably expected to
improve the patient's condition or for the purpose of diagnosis beyond the date in question. Based upon review
the records provided for the admission of this patient does not meet the criteria for continued acute inpatient
mental health treatment for the dates in question of June 18, 2021, forward as this patient was not shown to be a
danger to herself or others. She was not showing any auditory or visual hallucinations and was
cooperative/compliant with treatment while not showing any threats the 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 continued psychiatric services from June 18, 2021, and beyond have not been
met. Therefore, we decided that the Plan does not have to pre-approve continued mental health inpatient
psychiatric services from June 18, 2021, and beyond.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq and Abraxane.

You asked the Plan to pre-approve Tecentriq and Abraxane. You say that this drug regimen is medically necessary. The Plan denied your request. The Plan says this request is not medically reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Tecentriq and Abraxane. Our reviewer says that the requested drugs are not medically necessary and reasonable. Our physician reviewer found in this case; the enrollee has been diagnosed with triple negative metastatic breast cancer. The requested drug regiment is not FDA-approved for the enrollee's condition. In addition, the requested drug regimen is not approved in any Medicare approved compendia.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Tecentriq and Abraxane have not been met. Therefore, we decided that the Plan
does not have to pre-approve Tecentriq and Abraxane.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 22, 2021, through January 24, 2021.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that an inpatient level of care is not medically necessary due to the absence of a reasonable expectation of need for more than two overnights as there was no physician statement stating that it was expected member would require a prolonged stay.

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 midnight. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnight 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 documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the Emergency Department with a two-day history of epigastric abdominal pain and five episodes of non-bloody emesis on the day of arrival. The enrollee was treated with IV antibiotics and fluids. The computed tomography (CT) showed the gallbladder wall thickening, cholelithiasis. The diagnosis was cholecystitis. The enrollee declined surgery. The enrollee's fever persistent after admission and there was concern for perforation and development. Medical management was chosen by the enrollee and he was given oral administration of antibiotics. Based on the provided documentation, the enrollee was acute enough and was thought to possibly require surgery and due to persistent fever while attempting medical therapy only, close observation was necessary. It was expected that the enrollee would require hospital services that would likely cross two midnight.

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 provided from January 22, 2021, through January 24, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the rental charge of the neuromuscular electrical stimulation (NMES) device billed for date of service September 9, 2020.
You asked the Plan to pay for the NMES rental. You say that this was medically necessary and should be paid. The Plan denied your request. The Plan says there is no valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. There is some documentation that a delivery was made on April 8, 2020; however, the invoice only shows that an ankle brace was delivered on this date. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the rental charge of the neuromuscular electrical stimulation (NMES) device billed for date of service September 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of June 13, 2021.

You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of authorization for continued inpatient
psychiatric care is correct, because the enrollee is stable and can be stepped down to outpatient care.

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 psychiatric care. Our reviewer
says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care as of June 13,
2021. Our physician reviewer found it is not expected that the enrollee would improve in a reasonable period
beyond June 12, 2021, as he was not showing any dangerousness to self or others, auditory or visual
hallucinations, aggressive behaviors, or acute threats of safety. The enrollee was cooperative and compliant
with medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the
acute inpatient level of care rather than a lower level of care as of June 13, 2021.

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 psychiatric care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continued inpatient psychiatric care as of June 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 11, 2021.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 11, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services provided on February 19, 2020 by a PT assistant (PTA).
You asked the Plan to pay for the PTA services. You say that these services should be covered. The Plan denied your request. The Plan says this was not billed with the correct code.
The Plan must follow Medicare rules. Medicare rules say that PTA services should be billed by the supervising therapist. The services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. In this case, these therapy services were billed by a nurse practitioner. Therapy services cannot be covered
when provided incident to a nurse practitioner's services. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided on February 19, 2020 by a PT assistant (PTA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hearing services provided on August 17, 2020.You asked the Plan to waive the copayment for hearing services. You say that you were told that the services would be fully covered.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees inclear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for hearing services. You have been asked to pay a $45 copayment for hearing services. Hearing services fall within the hearing services 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 hearing services provided on August 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at 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 the services provided by an out-of-network provider on June 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on October 21, 2020.
You asked the Plan to pay for the self-administered drugs. You say that the nursing home expense was covered
but the hospital that preceded it was not covered. You say that you should be reimbursed for the hospital
charges. The Plan denied your request. The Plan says Part B generally doesn't pay for self-administered drugs.
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 pay for the self-administered drugs
provided on October 21, 2020.
Benefits for the self-administered drugs 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 patient was admitted to an acute care hospital for T9-pelvic fusion. Medical conditions are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that this patient 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.