Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the surgery services you received on October 20, 2020.
You asked the Plan to pay for the surgery services. You say that the Plan is your primary insurer, so this claim should be paid. The Plan denied your request. The Plan says that an Explanation of Benefits (EOB) from your primary insurer is required in order to pay for these services. The Plan claims that it has contacted this provider to request this EOB, but they have not been successful.
The Plan must follow Medicare rules. Medicare rules say that if a Plan contends that a primary payor exists, they are required to identify who that primary payer is, identify the amounts owed by the primary payer, and they are required to coordinate benefits with that primary payer. In this case, we do not find that the Plan has met this burden. The Plan has failed to identify who the primary payer is. The Plan has failed to provide any evidence as to what amounts this primary payer is responsible for. Finally, other than asking for an EOB from the provider (not the primary insurer), the Plan has not made any efforts at all to coordinate benefits with this primary payer. The Plan could try to coordinate benefits in a number of ways: the Plan could make provisional payment for the services and request recoupment from the primary insurer; the Plan could send the claims to the primary insurer directly; or the Plan could direct the provider to bill the primary insurer directly. None of these steps appear to have occurred here. Therefore, we find that the Plan has not met its burden and obligations related to coordination of benefits. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery services have been met. Therefore, we decided that the Plan has to pay for the surgery services you received on October 20, 2020.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prometheus Anser VDZ testing rendered on December 7, 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 testing was 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 pay for these services. Our reviewer says that the
testing was not medically necessary. Our physician reviewer found the enrollee has colitis. The clinical utility of measuring antidrug antibody concentrations has not been established, as it is not known how patient management would change based on test results. The Prometheus Anser VDZ testing is considered experimental/investigational in nature. The Prometheus Anser VDZ testing is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the Prometheus Anser VDZ testing rendered on December 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 skilled nursing home health visits.
You asked the Plan to pre-approve 18 skilled nursing home health visits. You say that this request is medically necessary to help manage your insulin pump. The Plan denied your request. The Plan says there is no evidence that you are confined to your home.
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be covered. The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-approve 18 skilled nursing home health visits
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvoya tablet for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.

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 Genvoya tablet for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat radiofrequency ablation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure has been done two times in the past year.

The Plan must follow Medicare rules. Medicare rules say that no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. 

The file shows that this same procedure has been received two times within the past year. The records show that the service was received on August 21, 2020 and September 4, 2020. 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 pre-approve a repeat radiofrequency ablation for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after August 27, 2021.
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for continued SNF care after August 27, 2021 is correct.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before August 27, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after August 27, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the head/brain for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical indication for immediate advanced imaging.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has a history of memory loss dating back to a traumatic injury on December 2016. Physical examination notes a neurological examination to show normal cognition. A mini-mental status examination is scored at 26. The record provided does not establish the medical necessity or reasonableness, as defined by Medicare rules of the requested service. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the head/brain 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-approve the LTACH services. You say that the enrollee's condition will require a multi-disciplinary approach for an extended period of time. The Plan denied your request. The Plan says the enrollee can receive all of the care required at the current 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 continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemtesa.
You asked the Plan to pre-approve Gemtesa. You say that other medications were not effective. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Gemtesa.
Benefits for Gemtesa 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pump (E0218).

You asked the Plan to pre-approve E0218. You say that this is medically necessary. The Plan denied your request. The Plan says this will be denied as not reasonable and necessary.

The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and necessary. 

The requested item is not considered medically reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of E0218 have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pump (E0218).
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 wants to be admitted to IRF to get stronger. 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 in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care visits.
You asked the Plan to pre-approve home health care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for home health care is correct.
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 the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer found the enrollee does not have documented skilled nursing or skilled therapy needs. As such, the home health skilled care and associated aide services are not medically necessary or 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 home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care visits.
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 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 in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the brain (70450).
You asked the Plan to pre-approve a CT scan of the brain. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 a CT of the brain. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation provided does not support medical necessity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the brain (70450).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says the current acute care hospital can provide acute care services until the member's condition allows transfer to an alternate level of care, such as skilled nursing facility, acute inpatient rehabilitation, home health care, nursing home, or home.
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 that the enrollee is a 71-year-old male who was admitted to the current acute care hospital with subdural hematoma following fall. He had worsening neurological exam findings and was treated with evacuation, drain placement, and intubation, but remained ventilation dependent, failing extubation several times. He is being treated for sepsis and pneumonia with 3 antibiotics and is requiring a nicardipine drip. The enrollee appears to not be stable enough for transfer currently as treatment for infection and sepsis
should be completed before transfer consideration. In the meantime, only short-term acute care services are expected and can safely be received in the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time as there appears to be no advantage. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable. 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 LTACH services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve urology services to be provided by an out-of-area provider.

You asked the Plan to pre-approve the requested services. You say that your bladder medication is no longer working. The Plan denied your request. The Plan says your needs can be met at an urgent care.

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 looked at the file, and Medicare rules. The requested urology services are not urgent or emergent. 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 urology services to be provided by an out-of-area provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurostimulator implantation.
You asked the Plan to pre-approve Percutaneous implantation of neurostimulator electrode array, epidural (63650). You say that the enrollee needs a spinal stimulator input to make it less painful to move around. The Plan denied your request. The Plan says the enrollee has not had maximal medical management.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record shows physical therapy is providing some relief and there is no psychological evaluation documentation. Based on this information, we decided that Medicare rules for coverage of Percutaneous implantation of neurostimulator electrode array, epidural (63650) have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurostimulator implantation.
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 need IRF care because of an injury. The Plan denied your request. The Plan says the records do not show you need an intensive program with a team that specializes in complex medical needs and rehabilitation.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.