Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that IRF care would benefit this enrollee.The Plandenied your request. The Plansaysthe enrollee does not require an intensive rehab program and would not likely be able to participate in three hours of daily therapy.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 is a female with a history of Parkinson's disease who presented to the hospital on 7/15 with right hip pain after a fall. She was found to have a right femur fracture requiring surgical repair. Her post-operative course has been complicated by atrial fibrillation with rapid ventricular response and metabolic encephalopathy. She is weak and deconditioned and is working with physical and occupational therapy. She is walking 2 feet with a rolling walker with maximum assistance x 2 and is moderate to total assist for transfers and activities of daily living. Her tolerance to therapy treatment has been reported to be poor. She is reported to be medically stable for transfer for further rehabilitation treatment. Transfer to an acute inpatient rehabilitation facility is requested.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 patient does require physical therapy and occupational therapy services but, based on the medical records provided, the patient does not require an intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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 carehave not been met.Therefore, we decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe oral evaluation provided on January 14, 2020.You asked the Plan to pay forthe oral evaluation. You say that you only went in for a regular cleaning not maintenance.The Plan denied your request. The Plan says out-of-network dental services are not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay forthe oral evaluation provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forrevascularization (37222) provided on November 13, 2019.You asked the Plan to pay forthe revascularization. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the service billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 37222 is revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure).We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the revascularization. Our reviewer says that CPT code 37222 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report has no documentation that this procedure was performed.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the revascularization have not been met.Therefore, we decided that the Plan does not have to pay forrevascularization (37222) provided on November 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary, as the general surgery team strongly believes the enrollee would greatly benefit from rehab.The Plan denied your request. The Plan says this 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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 SNF admission. You say that the enrollee needs skilled care due to the inability of his family to care for him at home.The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. While the enrollee does have skilled therapy needs, these needs are not on a daily basis. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 SNF admission 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay fora follow-up consultation provided while outside of the Plan's service area on July 26, 2018.You asked the Plan to pay forfollow-up visit. You say that you were under the impression that the Plan would continue to cover you for this service.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the service was not urgent or emergent in nature.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care.  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 follow-up visit. Our reviewer says that this service meets the Medicare criteria for coverage of urgent, out-of-area care. Our physician reviewer found you could not have foreseen requiring this service prior to leaving the Plan's service area. You had a dog bite on July 8, 2018. Pain and concern for infection persisted despite antibiotic therapy. There was concern for an allergic reaction to the antibiotics. The care provided was medically necessary. It would not have been medically reasonable to delay service until you returned to the Plan's service area or until after July 31, 2018 when you disenrolled from the Plan.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of follow-up visit have been met.Therefore, we decided that the Plan has to pay fora follow-up consultation provided while outside of the Plan's service area on July 26, 2018.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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
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 is with a history of closed head injury. She felt faint, and suffered a fall 6/14/2020. X-rays also revealed a right humeral neck fracture status post non-operative management. GCS was 15. Now, she is neurologically and hemodynamically stable. She is moderate assist for mobility, transfers, and activities of daily living. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly moderate assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.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 determineif the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with chronic obstructive pulmonary disease (COPD), gangrene to fingers and toes, chronic, due to Buerger's disease, admitted to acute care for black digits in setting of known Buerger's disease. From a nursing perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. He usedoxygen via nasal cannula. Regarding rehabilitation services, the enrollee did not have skilled therapy needs documented. The admission note indicates that he was 'mostly wheelchair bound'. There are no identifiable skilled nursing service needs.  There are no 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 SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injections.
You asked the Plan to pre-approve the Prolia. The Plan denied your request. The Plan says the information
submitted does not meet the Plan's medical necessity guidelines for coverage.
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 the Prolia. Our reviewer says that Prolia
injections do not meet the Plan's coverage criteria. Our physician reviewer found the Plan requires that
Zoledronic Acid be used. There is no evidence that the enrollee is allergic to or intolerant of Zoledronic Acid.
Our reviewer found that there is no evidence that the enrollee has tried and not responded to Zoledronic Acid.
There is no documentation as to why Zoledronic Acid would not be expected to be safe and effective for the
enrollee. Our physician reviewer also found that the requested Prolia is not shown to be currently medically
necessary and reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Prolia have not been met. Therefore, we decided that the Plan does not have
to pre-approve Prolia injections.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health visits (G0299). You asked the Plan to pre-approve continued home health visits. You say that the enrollee needs to continue receiving services. The Plan denied your request. The Plan says this is not medically necessary. 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 continued home health visits. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The records do not indicate complex wound care. The wound is closed and patient has had education on their medical conditions. There are no professional skilled nursing needs. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the patient's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent 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 continued home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health visits (G0299).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve combination therapy with carboplatin and Abraxane.
You asked the Plan to pre-approve the carboplatin/Abraxane treatments. You say that this is a medically
indicated treatment and should be approved. The Plan denied your request. The Plan says that there is no
evidence in the NCCN guidelines to support carboplatin/Abraxane for this diagnosis. However, there is good
evidence that Taxol rather than Abraxane is supported. Approval cannot be allowed for the use of Abraxane for
this patient's condition.
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 the carboplatin/Abraxane treatments.
Our reviewer says that the requested drug regimen is supported as medically reasonable and necessary. Our
physician reviewer found the enrollee has oropharyngeal cancer requesting an OPTIMA-like regimen due to
baseline neuropathy. This regimen is supported in the CMS-approved compendia. This is supported in the
Annals of Oncology from February 2019, " OPTIMA: a phase II dose and volume de-escalation trial for human
papillomavirus-positive oropharyngeal cancer" as well as in the Journal of Clinical Oncology study, "Dose and
volume de-escalation for HPV-associated oropharyngeal cancer: Long-term follow-up of the OPTIMA trial".
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 carboplatin/Abraxane treatments have been met. Therefore, we decided that
the Plan has to pre-approve combination therapy with carboplatin and Abraxane.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a prostatectomy (52601) provided from September 10, 2019 to September 20, 2019.
You asked the Plan to waive the coinsurance for a prostatectomy. You say that you feel you are being ripped off by the hospital. The Plan denied your request. The Plan says this processed 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 a 50% coinsurance for out-of-network outpatient surgery. You have been asked to pay a $1,819.82 coinsurance for a prostatectomy ($3,639.63 x 50% = $1,819.815). 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 coinsurance for a prostatectomy (52601) provided from September 10, 2019 to September 20, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits, three times per week for four weeks.
You asked the Plan to pre-approve the additional PT sessions. You say that it is felt that continued visits would allow for further functional improvement and are necessary to maintain current function. The Plan denied your request. The Plan says one weekly sessions for the next four weeks will be sufficient to ensure maintenance of functional recovery and allow for more training in the home exercise program.
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 the additional PT sessions. 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 enrollee has been receiving PT since June 1, 2020 after a knee surgery. She has had 20 visits so far. In this case, the requested additional therapy sessions are not generally accepted as specific and effective therapy for the patient's condition. The patient had had extensive therapy, minimal deficits on exam and participates in a home exercise program. The records do not indicate she requires the unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's 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 the additional PT sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits, three times per week for four weeks.