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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided January 24, 2020 to January 25, 2020.You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient hospital care provided was medically necessary.The Plan denied your request. The Plan says the acute inpatient hospital admission 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 the 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 that the enrollee was sent by her primary doctor to the Emergency Department (ED) on January 24, 2019 after finding a deep vein thrombosison her right leg after a two week history of right leg swelling. Aventilation-perfusion scan performed in the ED was negative for a pulmonary embolism. She was then started on Lovenox. The enrollee was admitted for further evaluation and treatment. She was evaluated by Hematology and was transitioned to Eliquis. She was then discharged home with outpatient follow-up on January 25, 2019. The review has determined that the record did not show that at the time of the inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BLS non-emergency ambulance service (A0428) and ground mileage (A0425) to a physician's office.You asked the Plan to pre-approve the ambulance service. You say that you cannot go to your doctor's appointment without the aid of an ambulance and you do not have any family.The Plan denied your request. The Plan says transportation to a physician's office is not covered.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pre-approve BLS non-emergency ambulance service (A0428) and ground mileage (A0425) to a physician's office.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve manual wheelchair anti-tipping device (E0971) positioning belt (E0978) battery charger (E2366) and adjustable footplate (K0040).You asked the Plan to pre-approve the wheelchair accessories. You say that in order to allow the enrollee to gain independence again in accessing necessary areas within her home in order to complete her MRADL's a power mobility device is recommended.The Plan denied your request. The Plan says these codes are included in the allowance for the approved Group 2 power wheelchair and cannot be billed separately.The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.The file shows that these codes are included in the allowance for the Group 2 power wheelchair and cannot be billed separately. Therefore, we decided that the Plan does not have to pre-approve manual wheelchair anti-tipping device (E0971) positioning belt (E0978) battery charger (E2366) and adjustable footplate (K0040).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transportation for non-medical needs, a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services.You asked the Plan to pre-approve transportation for non-medical needs, a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services. The Plan denied your request. The Plan says for an enrollee to be a candidate for these benefits he/she needs to have one or more of the eligible chronic conditions documented in the Evidence of Coverage for 2020 and require intensive care coordination, and must be at high risk of hospitalizations or adverse health outcomes. The enrollee does not meet any of these criteria and for this reason the benefits were denied.The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit yourhealth or general functioning.In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and the Plan's rules. The file shows that you do not have one or more of the qualifying diagnoses, you do not require intense care coordination, and you have no high risk for hospitalizations or high risk for adverse health outcomes. Based on this information, we decided that the Plan's rules for coverage of transportation for non-medical needs, a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services has not been met. Therefore, we decided that the Plan does not have to pre-approve transportation for non-medical needs, a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom shower chair.
You asked the Plan to pre-approve a shower chair. You say that this is needed as you are unable to walk or stand. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a custom shower chair.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321).
You asked the Plan to pre-approve Hyalgan. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Hyalgan. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan (J7321).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says services can be safely received in other settings.
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 you were medically stable, with no evidence of need for supervision by a PMR
physician. There is no need for acute rehab nursing care. Functionally, given that you are minimum assist level,
your rehab needs can be easily provided in a SNF setting. You may benefit from further PT and OT, but does
not require an intensive therapy program. The admission is not medically necessary, based on your current
functional status and medical stability.
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).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from acute rehab to optimize her level of functioning prior to returning home. The Plan denied your request. The Plan says if the enrollee requires ongoing acute level care, the enrollee should remain in the current setting until a time frame where no further acute level care is needed.
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 you were medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. You may benefit from further PT and OT, but you do not require an intensive therapy program. This admission is not medically necessary, based on the enrollee's current functional status and medical stability. 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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea portable oxygen concentrator.You asked the Plan to pre-approvea portable oxygen concentrator. You say that you are unable to carry oxygen tanks and are unable to walk for more than 40 feet without gasping for air.The Plan denied your request. The Plan says there is no documentation from a physician ordering oxygen or that testing has been done.The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygenin the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.  To qualify for home oxygen, the patient must meet one of the following blood gas levels:1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.We looked at the file, and Medicarerules. The physician notes state that your oxygen levels are at 99%. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator have not been met.Therefore, we decided that the Plan does not have to pre-approvea portable oxygen concentrator
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. 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 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 services are not medically necessary. Our physician reviewer found the enrollee was seen in the emergency department on May 26, 2020 for community-acquired pneumonia and dehydration. She was treated and sent home on May 27, 2020 to continue antibiotics as an outpatient. She is medically stable. There is no evidence of complex medical issues that require monitoring by inpatient physical medicine and rehabilitation or acute rehab nursing care. She does not require an intensive therapy program in an IRF. The IRF services are 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter identified with code K0800.
You asked the Plan to pre-approve a power scooter. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power scooter. Our reviewer says that the documentation does not support that the requested power scooter is medically reasonable or necessary. Our physician reviewer found you have a personal mobility deficit, but the documentation is not consistent that the deficit impairs participation in mobility related activities of daily living. According to the therapy evaluation on January 22, 2020, you are able to use a Rollator walker and have modified independence with many activities of daily living during a typical day. The physical therapy evaluation noes no ataxia/dysmetria in the upper limbs and normal bilateral upper extremity and bilateral lower extremity strength and range of motion. The documentation is inconsistent that your mobility deficit is unable to be helped by the use of a walker as the documentation notes that you use a rollator and is moderate independent with most activities of daily living per a January 22, 2020 evaluation, which has conflicting statements including that you are unable to use a walker to remedy your mobility deficit. The documentation has conflicting information. Therefore, you do not meet criteria for the requested device. 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 power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter identified with code K0800.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.
You asked the Plan to provide a Group 3 power wheelchair and accessories. You say that the enrollee needs a Group 3 power wheelchair, seat lift, and accessories. The Plan denied your request. The Plan says the records do not show a qualifying diagnosis, a seat lift is not covered by Medicare, and a cup holder is not medical in nature.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GELSYN.You asked the Plan to pre-approveGELSYN. You say that the requested GELSYN is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve GELSYN. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with osteoarthritisof the knee. The Plan's step therapy criteria require previous treatment, contraindication, or intolerance to Orthovisc and Monovisc. The documentation submitted includes chart notes and physician statement. The documentation submitted does not support that the enrollee has had prior treatment, contraindication, or intolerance to the preferred alternatives Orthovisc and Monovisc. The prescriber does not state why the alternatives required by the Plan (1) would not be as effective for the enrollee as the requested drug; and/or (2) would have adverse effects for the enrollee. Therefore, an exception to these criteria is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor coverage of GELSYN have not been met.Therefore, we decided that the Plan does not have to pre-approveGELSYN
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.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 ACH for sepsis in the setting of a recent positive CoViD-19 test and recent treatment for sacral osteomyelitis. The enrollee is not intubated/ventilated. The enrollee is receiving antibiotics, wound care and tube feeds. 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. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-termcare 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 Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansayscare can be provided in the current inpatient 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 andnecessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for COVID-19. The enrollee was initially intubated/ventilated for airway protection due to epistaxis. The enrollee subsequently suffered a cardiac arrest. The enrollee has since received a tracheotomy and is tolerating CPAP settings on the ventilator. The enrollee is noted to be unresponsive and appears to have a poor prognosis. 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. The enrolleecan 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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.