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

We decided that the Plan does not have to pre-approve an IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says admission to an IRF is not medically necessary and does not meet criteria. The Plan says that the enrollee can safely receive the services in other settings such as a skilled nursing facility, home with home health and home physical 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 that the enrollee does not have a medically complex condition which requires close supervision in an acute hospital inpatient setting, with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee in this case requires at least 3 hours a day, 5 days a week. 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 an IRF admission and services.
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 services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, you are mostly maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear you would be able to fully benefit and/or participate in an IRF 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 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 you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested admission 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 LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee's ongoing care needs include intermittent BiPAP, nebulizer treatments,
isolation precautions and treatment for Clostridium difficle infection, surveillance laboratory studies, fluid
balance, tube feeding, and therapy services. The documentation does not support that the enrollee in this case
requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently
receiving care. There are no required medical services identified that are available at the LTACH, that are not
available at the current health care setting being offered by the health 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 20, 2019.
You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says a secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service.
The Plan must follow Medicare rules. The rules say that health plans, physicians, hospitals, and other health care providers must comply with the Official ICD-10-CM Coding Guidelines. In this case, the primary diagnosis code you used is a secondary code. We find that the ICD-10 Coding Guidelines states that certain codes should not be reported first since they are manifestations of an underlying condition and the underlying condition should be coded first. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued hospital care under inpatient status. You asked the Plan to pre-approve continued inpatient care. The Plan denied your request. The Plan says inpatient care is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued inpatient care. Our reviewer says that the requested inpatient care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was admitted on June 6, 2020, to observation status due a status post fall at home, resulting in the right acetabulum fracture. The orthopedic physician was consulted, and no surgical intervention was recommended. She was evaluated by physical therapy (PT) who recommended SNF placement for short term daily skilled rehab; but family refused. The enrollee was recommended a discharge to SNF on June 8, 2020. On June 9, 2020, the enrollee was diagnosed with UTI and treated with intravenous Rocephin and IV fluids for mild elevation in BUN. The treating team determined that the enrollee no longer requires the necessary services of personnel, diagnostic or therapeutics that can only be safely and effectively be provided in the hospital environment including observation status. The enrollee was advised for SNF placement for physical/occupational therapies and medications management. The advocate refused SNF admission, requesting skilled services at a hospital. There is no documentation provided necessitating continued hospital level of care services beyond June 12, 2020. 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued hospital care under inpatient status.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bilateral blepharoplasty (15823 X 2) provided on September 10, 2019.
You asked the Plan to pay for the services. You say that the service is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. Under Medicare guidelines, your request is not medically necessary because your records show you do not have the required visual field abnormalities to indicate a functional deficit to warrant approval for this
surgery. Therefore, we decided that the Plan does not have to pay for the bilateral blepharoplasty (15823 X 2) provided on September 10, 2019
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 records provided support the need for IRF care.The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of IRF care. The Plan says that the enrollee's needs could be met in an alternate 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on December 19, 2019.
You asked the Plan to waive the copayment for the medical eye exam. You say that this was a routine eye exam. The Plan denied your request. The Plan says this was not a routine eye exam.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received a medical eye examination provided on December 19, 2019. You are asked to pay a $40 copayment for the medical eye exam. 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 medical eye exam provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health care.You asked the Plan to pre-approvehome health care. You say that home health care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.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 home health care. Our reviewer says that Medicare coverage criteria are not met. 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 your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The records do not show home care is required in the form of skilled therapy to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. The documentation does not support that continued physical therapy home health visits are medically reasonable and necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of home health care have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health care.
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 SNF services. You say that continued SNF services are medically necessary. The Plan denied your request. The Plan says Medicare criteria for continued SNF services are not met.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of June 1, 2020, daily skilled nursing and daily skilled therapy services are not required. As of the date in question you do not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Medicare coverage criteria are not met. 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem Tartrate tablets.
You asked the Plan to pre-approve Zolpidem Tartrate. You say that the medication is medically necessary. The Plan denied your request. The Plan says coverage for this drug is not available under the Part B benefits.
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 Tartrate tablets.
Benefits for Zolpidem Tartrate 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 a stem cell therapy injection (Floweraminoflo).
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says this is an experimental treatment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, stem cell injection therapy for arthritic joints is not considered standard of care. Some studies demonstrate effectiveness of this modality for the treatment of osteoarthritic changes as well as other medical pathology. However, studies do recommend further double-blind placebo-controlled studies in order to solidify the effectiveness of this treatment. In most circles, this treatment modality is considered experimental for the treatment of osteoarthritis. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a stem cell therapy injection (Floweraminoflo).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four skilled nursing visits, four physical therapy visits, and eight home health aide visits.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have acute respiratory failure due to the flu. The records do not show that you need the requested skilled nursing services to effectively provide treatment, care, and/or services to improve your condition, or to establish/perform a maintenance program to maintain your condition or prevent deterioration. Skilled therapy is not required to improve your level of function or to establish a maintenance program. Your current functional level does not require skilled therapy beyond the authorized services. The records do not support that home health services are necessary for treatment of your illness or injury.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve four skilled nursing visits, four physical therapy visits, and eight home health aide visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 12, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for portable oxygen equipment (E1392, A9270) provided
November 4, 2019 to February 3, 2020.
You asked the Plan to pay for the portable oxygen equipment.. You say that the oxygen supply is medically
necessary. The Plan denied your request. The Plan says the item was obtained out-of-network. No prescription
or order from the physician was provided for the oxygen equipment at issue.
The Plan must follow Medicare rules. Medicare rules say that a new prescription (order) is required when an
enrollee obtains new Durable Medical Equipment.
We looked at the file and Medicare rules. The record did not include a physician's order for the oxygen
equipment. Based on this information, we decided that Medicare rules for coverage of the portable oxygen
equipment. have not been met. Therefore, we decided that the Plan does not have to pay for portable oxygen
equipment (E1392, A9270) provided November 4, 2019 to February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on January 29, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 forthe drug testing services provided on January 29, 2020.
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 therapy had you practicing on 4 stairs, but
you have 14 stairs at home. The Plan denied your request. The Plan says you have reached baseline, and do not
require daily skilled services.
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 services beyond June 10, 2020, 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 you are post intracerebral
hemorrhage. You have limited mobility. Recent records indicate ongoing assistance is needed for bed mobility
and activities of daily living. You are stable neurologically and hemodynamics are stable. You have no
complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are
skilled, and warranting a SN. Therefore, continued SNF care is 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 continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) services.