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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says the enrollee does not require placement in a skilled facility for therapy, and does
not require a licensed professional to assist with dressing.
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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The 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 the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on March 20, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately paid.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are
statutorily excluded.
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.
Therefore, we decided that the Plan does not have to pay for the special pump services rendered on March 20,
2020.
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 services are necessary. The Plan
denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 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 they are 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. The clinical assessment in the case file does not support
that the enrollee is reasonably expected to benefit from, and improve with, hospice services. The requested
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of
the enrollee at this time.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on February 21, 2020.
You asked the Plan to pay for the pump operation and assembly. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room through the duration of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump operation and assembly have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on February 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient alcohol rehabilitation for the enrollee. You asked the Plan to pre-approve inpatient alcohol rehabilitation. You say that these services are medically necessary.The Plan denied your request. The Plan says that the appropriate alternative level of care would be outpatient.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 inpatient alcohol rehabilitation. Our reviewer says that inpatient alcohol rehabilitation is not considered medically reasonable and necessary in this case. Based upon review the records provided it is not expected this enrollee would improve in a reasonable period of time as she does not have dangerousness to self or others and is not showing any delusions or auditory/visual hallucinations while not showing any aggressive behaviors. She is not exhibiting any withdrawal behaviors. 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 she does not have dangerousness to self or others. This enrollee does not appear to require inpatient mental health treatment as she is not a danger to herself or others and is cooperative with care without any aggressive behaviors or withdrawal from alcohol. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of inpatient alcohol rehabilitation.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 alcohol rehabilitation have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient alcohol rehabilitation for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee is able to functionally tolerate this level of care.The Plan denied your request. The Plan says there is a lack of medical complexity, and the enrollee has an inability to tolerate 3 hours of therapy per day.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee is weight-bearing at times. She is medically and surgically stable. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. She may benefit from multiple therapies, such as physical and occupational therapy, but the documentation does not support that the enrollee's functional status requires or can tolerate an 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve the SNF services. You say that the enrollee still qualifies for coverage of SNF care and is improving with therapy.The Plan denied your request. The Plan says there is no clear benefit of inpatient skilled nursing as opposed to an alternative setting for care. The Plan says that the specialized skill, knowledge, and judgement of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and clear lungs. The enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a contact guard to minimal assist to contact guard assist level with functional mobility, including gait to 175 feet with a quad cane. The enrollee was independent with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a preventive medicine reevaluation (99397) provided on
March 4, 2020.
You asked the Plan to pay for the preventive medicine services. You say that you would like reconsideration
because you have never been charged for a physical in the past. The Plan denied your request. The Plan says
preventive medical exams are not a covered benefit.
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 99397
is periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older.
We find that CPT code 99397
is not supported in the record. Specifically, this preventive medical service is not covered by Medicare or the
Plan. Based on this information, we decided that Medicare rules for coverage of the preventive medicine
services have not been met. Therefore, we decided that the Plan does not have to pay for a preventive medicine
reevaluation (99397) provided on March 4, 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 you want to return to being independent, want 3 hours of intensive therapy per day, and need to be seen by a rehabilitation or general medicine physician daily. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. While you may benefit from multiple therapies such as physical and occupational therapy, the documentation does not support that your functional status requires or could tolerate an 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOrthovisc knee injections.You asked the Plan to pre-approveOrthovisc. You say that there is continuedevidence of some pain and inflammation secondary to arthritis.The Plan denied your request. The Plan says there are currently no clinical indications for this treatment.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Orthovisc. Our physician reviewer found that the enrollee has bilateral knee pain. Mobic and Norco have not helped, but previous viscosupplementation did provide relief. The most recent visit reports the enrollee's knees have gradually worsened. Per literature, viscosupplementation, the intra-articular injection of hyaluronic acid, produced "minimal or nonexistent" effects on pain and function in patients with knee osteoarthritis, but did increase the risks for serious adverse events and local adverse reactions. The documentation does not support that Orthovisc is medically reasonable and necessary for the enrollee. The documentation does not support that Orthovisc is safe and effective 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approveOrthovisc knee injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 panel rendered on March 10, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel mustbe billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 pay forthe Guardant360 panel rendered on March 10, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair out of network.
You asked the Plan to pre-approve out of network providers. You say that this equipment is medically
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not have out of
network durable medical equipment benefits.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the items at issue in this appeal. We found no exception that would require the Plan to preapprove
these items out of network. Therefore, we decided that the Plan does not have to pre-approve a power
wheelchair out of network.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lesion destruction, biopsy, and pathology services.
You asked the Plan to pre-approve the requested services. You say that your severe chronic rash is getting
worse. The Plan denied your request. The Plan says the services are being requested for cosmetic purposes.
The Plan follows Medicare rules. Medicare rules say that Corrective facial surgery will be considered cosmetic
rather than reconstructive when there is no functional impairment present.
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 requested services. Our physician
reviewer found that the requested service is considered cosmetic in nature. The post-inflammatory
hyperpigmentation is cosmetic in nature and usually self-limited. Therefore, the requested services are not
medically reasonable and necessary to treat your condition.
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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve lesion destruction, biopsy, and pathology services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lumbar transforaminal epidural steroid injection (TFESI).You asked the Plan to pre-approvethese services. You say that the enrollee needs an L3 and L4 injection after receiving one at L5.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a TFESI is covered when specific criteria are met.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 enrollee has back pain due to recurrent disc herniation. He received a prior L5 TFESI that provided pain relief for two days. The Medicare rules require pain relief of at least three months' duration from a previous injection for approval of a repeat injection. The criteria for coverage are not met and the repeat injection is not reasonable or medically necessary at this time.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-approvea lumbar transforaminal epidural steroid injection (TFESI).
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 care in an IRF.The Plan denied your request. The Plan says the records do not show a need for the enrollee to be seen by a rehab doctor three times per week or an intensive team for care. The Plan says that the enrollee can safely receive the services needed in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but, based on the medical records provided, does not require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Continued care at the skilled nursing facility level appears to be more appropriate in this case.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 the services are medically necessary.The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for respiratory failure following surgery. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee is tolerating ventilator weaning. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required.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.