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

We decided that the Plan does not have to pay for observation care and management services (99236) provided August 22, 2019.
You asked the Plan to pay for observation services. You say that you should have received a facility claim for the same date of service to verify that the enrollee's type of service as "emergency related" The Plan denied your request. The Plan says no authorization of out of network services.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. You provided physician services to the enrollee while in observation status in a facility. Payment for this service would have been included under the facility claim for observation. Payment to you for this service is the responsibility of the facility or hospital. Therefore, the plan is not required to pay you separately for this claim.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve the Prolia. You say that the Prolia is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says the documentation does not support the medical necessity for a step therapy exception.
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 the Prolia. Our reviewer says that the member has not tried and failed a trial of zoledronic acid. Our physician reviewer found the documentation does not support that zoledronic acid would likely be less effective or have adverse effects.
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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abutment supported porcelain fused to metal crown (D6059) and a prefabricated abutment (D6056) for teeth # 13 and 14.
You asked the Plan to pre-approve the dental services. You say that your dentist put in metal plates for the crowns already. You say that the gum is going to grow over and therefore you need these services. You also say that you are on disability and cannot afford the out of pocket cost. The Plan denied your request. The Plan says the requested services are not listed as covered.
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 requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an abutment supported porcelain fused to metal crown (D6059) and a prefabricated abutment (D6056) for teeth # 13 and 14.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the medication toxicity and pain management stay, for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that the is medically necessary. The Plan denied your request. The Plan says that the stay is 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee will require inpatient services to undergo withdrawal from medications and the initiation of Buprenorphine. The review indicates that the record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the medication toxicity and pain management stay, for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits.
You asked the Plan to pre-approve the additional PT visits. You say that you believe you require additional PT for your condition. The Plan denied your request. The Plan says ongoing PT is not likely to be helpful and you can receive a similar benefit by transitioning to a home exercise program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found The documentation does not reveal objective functional improvement from prior shoulder therapy therefore an additional 10 visits of therapy cannot be considered to be effective for this condition. The patient has had 7 visits of therapy and should be able to transition to an independent home exercise program. The unique skills of a professional therapist are not required to safely and effectively provide treatment, be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you need the requested incontinence supplies because you were in the hospital recently and had a urinary tract infection. You say that you cannot hold your urine and this incontinence has caused you to fall a few times. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on May 31, 2019.You asked the Plan to pay forthe ambulance services.. You say that the services were medically necessaryThe Plan denied your request. The Plan says the enrollee was medically stable at the time of transport and the enrollee could have beensafely transported by another type of vehicle.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance services.Our physician reviewer found the enrollee wastransported by ambulance from the hospitalto a rehabilitation facility. BLS transport from hospital to skilled nursing facility did not meet criteria. The rules say that ambulance services are only covered when the patient's clinical condition is such that other methods of transport are contraindicated.  There was no specific clinical rationale for the ambulance transportation. The review has determined that the enrollee did not meet the requirement for ambulance service A0428HN, A0425HN, hospital to nursing facility.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 ambulance services. have not been met.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on May 31, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient hospital care provided after 10am on July 13, 2019 to July 18, 2019.You asked the Plan to pay forthese services. You say that the inpatient hospital care provided was medically necessary.The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized by 7:27 a.m. on July 13, 2019 and subsequent care was post stabilization care, not approved in compliance with the health plan's authorization procedures. The Plan has paid for all emergent care up to 10:00 a.m. on July 13, 2019.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post-stabilization of care services provided at the non-Plan facility after 10:00am on July 13, 2019 were not medically necessary and reasonable. Our physician reviewer found that thedocumentationindicatedby 10:00 a.m. on July 13, 2019, the enrollee's emergency medical condition had been stabilized. At 7:27 a.m., the enrollee was evaluated by the Trauma Surgeon and her left femur fracture was stabilized. The enrollee had been treated with IV fluids and IV narcotic medications for pain control. All of the enrollee's laboratorytests and imaging confirmed that her acute orthopedic emergency had been stabilized.The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of 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 these services have not been met.Therefore, we decided that the Plan does not have to pay forthe inpatient hospital care provided after 10am on July 13, 2019 to July 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhospital services provided to the enrollee on July 19, 2019.You asked the Planto pay forthis is medically necessary.. You say that this is medically necessary.The Plandenied your request. The Plansaysthe service obtained by the enrollee was rendered by a provider who is not under contract with this health 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requestedprovider 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. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plandoes not haveto pay forhospital services provided to the enrollee on July 19, 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 requires inpatient rehabilitation and cannot be discharged to a lower level of care because she is at risk for not regaining full function and at risk for acute rehospitalization. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for admission to an IRF.
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's medical conditions appear stable and there are no wound care needs. There are no unaddressed medical issues and the enrollee does not require medical oversight of her condition at an acute hospital level of care. The enrollee 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 enrollee's need for any adaptive equipment. The enrollee is ambulating greater than household distances and is performing essential activities of daily living without hands-on assistances. 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. The member's care can be appropriately provided through home-based and outpatient services. 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 these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 these 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) following a large stroke. The enrollee was intubated/ventilated and eventually received a tracheotomy. The enrollee has been weaned from the ventilator. 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 these 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on review of the available records, the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by a Physical Medicine and Rehabilitation (PMR) Physician or needs acute rehab nursing care. They may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF 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 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that 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 medical records indicate that the enrollee does not meet the IRF admission criteria due to lack of medical complexity. The records further show the enrollee will not tolerate the IRF intensity of care. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebone marrow aspiration (20939).You asked the Plan to pre-approvebone marrow aspiration. You say that the services are medically necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. 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 bone marrow aspiration. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the planned cervical spine surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition. Therefore, the request for bone marrow aspirate is not medically reasonable and necessary for the approved anterior cervical discectomy and fusion.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met.Therefore, we decided that the Plan does not have to pre-approvebone marrow aspiration (20939).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient mental health care from August 27, 2019 through August 31, 2019.You asked the Plan to waive the copayment forinpatient mental health care. You say that you are appealing your cost-share responsibility for the services you received.The Plandenied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on August 27, 2019 and discharged on August 31, 2019. You were asked to pay a $250 copayment per day from August 27, 2019 through August 30, 2019, days 1-4 of your inpatient hospital care. You were discharged on August 31, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $325 copayment per day required for days 1-5. 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 forinpatient mental health care from August 27, 2019 through August 31, 2019.