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).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member was admitted for acute care on 01/15/2020. She had slipped out of bed the night before. She was treated for hypertensive urgency and sepsis. She lives in a split-level residence with ramp access and had been independent and had occasionally required assistance with lower body dressing. The member had been using a rolling walker and had not used stairs since July 2019. The member was admitted for SNF level care on 01/22/2020. She has a diagnosis of left lower extremity deep vein thrombosis. Her relevant past medical history included hypothyroidism, memory impairment, and trigger finger release surgery. Functionally, the member is able to ambulate 150 feet with a rolling walker and contact-guard assistance and requires supervision for bed mobility and transfers. She was discharged from physical and occupational therapy on 02/04/2020. She has pain being treated with acetaminophen and tramadol.
The member is status-post acute care admission as described above and was receiving SNF level care. The member requires oversight of her medical conditions and medication management. The member requires physical therapy for progression of her mobility at a community level and to establish a maintenance home exercise program. An occupational therapy evaluation is indicated to assess the need for any adaptive equipment. There are skilled needs, but they do not need to be provided on a daily basis. The member is ambulating greater than household distances and performing essential activities of daily living without hands on assistance. The member is receiving care that can be provided by her non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed. The member's condition would not be expected to deteriorate with services provided on a less than daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a skilled nursing facility (SNF) have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: 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 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 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 admission to an IRF does not meet criteria. Our physician reviewer found the member was admitted for acute care on 02/13/2020 with small bowel ischemia. He underwent an exploratory laparotomy with small bowel resection. He returned for a small bowel anastomosis and mesenteric artery stent on 02/15/2020. He has a relevant past medical history that includes end-stage renal disease with hemodialysis 3 days/week. The member lives alone in a single level residence with one-step to the entrance and had been independent. He has left eye blindness with reduced vision (20%) in his right eye. As of 02/21/2020 he required standby assistance for bed mobility and transitioning from seated to supine. He required minimal assistance when transitioning from seated to standing and hands-on assistance when ambulating 100 and then 150 feet with a rolling walker.
He had a slow reciprocal gait pattern with narrow base of support and tended to stay to one side of the walker. He had a flexed posture. He then ambulated 100 feet without an assistive device and minimal assistance with one loss of balance. The member is status-post acute care admission as described above. The member's medical conditions appear stable. There are no complex wound care needs. There are no unaddressed medical issues. He does not require medical oversight of his condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. He is ambulating greater than household distances and does not require an intensive rehabilitation therapy program.
The member's medical conditions appear stable and he is participating in the treatments being provided. He would be expected to be able to fully participate and benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Next Generation Sequencing (NGS) for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee had a recent thyroid biopsy that showed a follicular lesion of unknown significance. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that NGS is covered for patients with either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. We looked at the file and Medicare rules. The file shows that the testing is being requested for a non-toxic goiter. The enrollee does not have a personal history of recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 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 Next Generation Sequencing (NGS) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from March 25, 2019 to April 23, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are not coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require any additional skilledservices that could not have been provided in an alternate setting other than a SNF.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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from March 25, 2019 to April 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exercise program.
You asked the Plan to pre-approve an exercise program. You say that this program would benefit the enrollee. The Plan denied your request. The Plan says this program is not covered by Medicare or the Plan.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only from a participating fitness center, or exercise center. The Plan's rules for coverage of gym benefits have not been met because the exercise program is not a participating fitness center or exercise center. Therefore, we decided that the Plan does not have to pre-approve an OsteoStrong exercise program.
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. The Plan denied your
request. The Plan says the enrollee would be approved for therapy in a skilled nursing facility.
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 currently medically stable and there is no evidence of complex
medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute
rehab nursing care. While she may benefit from continuing ST, PT and OT, there is no evidence of need for an
intensive therapy program with therapy 3 hours per day with frequent physician oversight and an
interdisciplinary approach to rehabilitation 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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-approvethe LTACH services. You say that this is the safest discharge plan and allows the enrollee the highest potential level of function for recovery. You say that LTACH care will prevent further deterioration and is the best use of medical management.The Plan denied your request. The Plan says the records do not show that it is medically necessary for the enrollee to be in an LTACH in place of an acute care hospital.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 is currently undergoing treatment at an acute care hospital (ACH) for end-stage chronic obstructive pulmonary disease (COPD) complicated by a deep vein thrombosis (DVT) and infectious diarrhea. Theenrollee is not intubated/ventilated. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you the full amount forthe periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on August 20, 2019.You asked the Plan to reimburse you the full amount forthe dental services. You say that the services you received on August 20, 2019 qualify for reimbursement. You say that the reimbursement of the $190 payment you made for the dental repair appointment on August 23, 2019 has not been denied. You also say that you have not yet received a check for that amount.The Plan denied your request. The Plan says the claim for date of service August 20, 2019 processed after the claim for date of service August 23, 2019. The Plan says that the claim for August 20, 2019 was paid up to the $500 maximum yearly allowance. The Plan also says that you are responsible for the remaining amount.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, the annual allowance of $500 has been exceeded. Therefore, we decided that the Plan does not have to reimburse you the full amount forthe periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on August 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography (CPT 95810) for the enrollee.
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says CPT 95811 has already been approved.
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 study. Our reviewer says that the requested study is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has severe obstructive sleep apnea. A previous CPAP titration in 2016 was not successful. The enrollee was placed on a trilogy ventilator, but apparently without a demonstration of medical necessity, and it is no longer being covered. A repeat PAP titration study, possibly including BiPAP titration, is medically necessary, and the Plan has approved that test, CPT 95811. 95810 duplicates the diagnostic portion of 95811, and 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 the study have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography (CPT 95810) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided August 9, 2019 to August 10, 2019.Youasked the Plan to pay foracute inpatient hospital care. You say that the clinical outline contained in the medical records clearly outlines there was a risk for an acute adverse event and the hospitalization was medicallynecessary.The Plan denied your request. The Plan says the member did not require or receive care at an inpatient level to support the authorization of the request. The request for coverage for the inpatient hospital admission was not authorized as the inpatient stay was not medically necessary. 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 midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the patient presented to the emergency department (ED) with erythema that had extended to her right cheek with swelling. On evaluation, the vital signs were not actionable. Her condition stabilized and improved, and she was discharged home on August 10, 2019 on oral antibiotics with outpatient follow-up in 5-7 days.The documentation does not support that it was reasonable for the admitting physician to expect that the enrollee's necessary hospital care would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided August 9, 2019 to August 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 enrollee meets the full criteria for inpatient rehabilitation stay. You say that the enrollee's current needs cannot be safely be met at a lower level of care.The Plan denied your request. The Plan says the guidelines for coverage 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 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.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 pre-approve a referral to an out-of-network provider for the enrollee.
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 available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 9, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because you were not treated and did not need to go to the emergency room. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you were evaluated in the emergency room.
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 emergency room visit provided on October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift recliner.You asked the Plan to pre-approvethe seat lift mechanism of a seat lift recliner. You say that due to recent surgery and limited strength the enrollee needs a seat lift recliner.The Plan denied your request. The Plan says The medical records do not support medical necessity for a seat lift mechanism.The Plan must follow Medicare rules. The rules say that a seat lift mechanismis covered if all of the conditions listed above are met. Medicare does not cover the upholstered portion of a seat lift recliner.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the seat liftmechanism of a seat lift chairhave not been met.Therefore, we decided that the Plan does not have to pre-approvethe seat lift mechanism of a seat lift recliner.
Appeal type: Practitioner Services
Decision: Unfavorable

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