Persius/hicric huggingface dataset:
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 services can be received in another setting, such as a skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.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 was medically stable with no evidence of need for supervision by PMR Physician or needs acute rehab nursing care. He is functioning well requiring very little assistance. He may benefit from further PT and OT but does not require an intensive therapy program. IRF admission is not medically necessary based on her 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) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to hold you harmless forservices provided to you from September 11, 2019 to October 2, 2019.You asked the Plan to hold you harmless forthe services. You say that these services should be covered.The Plan denied your request. The Plan has only addressed the therapeutic activities billed on October 2, 2019 andsays that the documentation does not support the services as billed.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. the plan follows these rules. The file does not show that plan's provided notice that the services would not be covered. Under Medicare rules, this means the services areconsidered approved by the planTherefore, we decided that the Plan has to hold you harmless forservices provided to you from September 11, 2019 to October 2, 2019.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have topre-approvecold therapy (fluid circulating cold pad with pump).You asked the Plan to pre-approvethe therapy. You say that this is medically necessary.The Plan denied your request. The Plan says cold therapy is not covered by Medicare for any indication.The Plan must follow Medicare rules. Medicare rules say that cold therapy is not a covered benefit.The requested therapy is not covered by Medicare for any indication. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met.Therefore, we decided that the Plan does not have to pre-approvecold therapy (fluid circulating cold pad with pump).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for admission to inpatient status.
You asked the Plan to pay for the inpatient admission. You say that it is felt that inpatient admission is warranted. The Plan denied your request. The Plan says the enrollee was sent to a SNF where she left voluntarily, then returned to the ED asking to be placed in another SNF. There is no need for acute inpatient admission.
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 inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the enrollee had a known patellar fracture and had been receiving care at a rehabilitation facility. The enrollee left the facility related to dissatisfaction with care and returned home. The enrollee presented to the emergency department on 2/29/20 requesting admission to a different rehabilitation center. The medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. She had stable vital signs and no complaints at the time of admission. Inpatient services were not supported by the documentation. 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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pay for admission to inpatient status.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care beyond March 11, 2020.You asked the Plan to pre-approve the continued inpatient mental health services. You say that the enrollee would benefit from remaining in the current setting.The Plan denied your request. The Plan says the enrollee is not receiving active care and can be managed in the outpatient setting.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient mental health services. Our reviewer says that the enrollee no longer meets criteria for inpatient psychiatric care. Our physician reviewer found this 48-year-old female was involuntarily admitted to the acute inpatient psychiatric hospitalization on March 3, 2020 with Alcohol Use Disorder, Severe, Bipolar Disorder Type I Mixed, Severe with Psychotic Features, Cannabis Use Disorder and Stimulant Use Disorder. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was compliant with treatment while not showing any acute threats to safety as she had future plans. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. The health plan's denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question.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 continued inpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care beyond March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on October 29, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you did not think you would have to pay for a follow-up appointment.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 $50 copayment for each Medicare-covered specialist office visit. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up appointment.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 forthe specialist office visit provided on October 29, 2019.
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 this is medically necessary.The Plan denied your request. The Plan says the enrollee is medically stable, and continued care could be better provided in a skilled nursing facility setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH following a stroke. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has been weaned from the ventilator to a tracheotomy collar. 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 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-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiac rehabilitation provided on October 28, 2019 and October 30, 2019.You asked the Plan to waive the copayment for cardiac rehabilitation. You say that you were not informed of a charge per visit. You say that you were told it was covered.The Plan denied your request. The Plan says the copayments applied correctly.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 $20 copayment for each therapy visit. You have been asked to pay a $20 copayment for cardiac rehabilitation. Cardiac rehabilitation falls within the "Outpatient rehabilitation services" benefit category. 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 cardiac rehabilitation provided on October 28, 2019 and October 30, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve the inpatient psychiatric hospital services. You say that inpatient psychiatric hospital services are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for inpatient admission due to lack of Axis 1 diagnosis, a psychiatric comorbid condition, and suicidal or homicidal ideation.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on March 6, 2020 with Dementia Due To Vascular Origin with Behavioral Disturbance. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance including auditory or visual hallucinations. The health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. The enrollee was not shown to be a danger to himself or others, was without agitation or aggression, and was without perceptual disturbance including auditory or visual hallucinations.
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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on September 30, 2019You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate claim.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The services in question were billed on a claim that is considered to be a duplicate of a claim previously processed and paid by the plan. 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 pay for the services provided to the enrollee on September 30, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says that you do not meet step therapy criteria.
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 Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Retacrit (Epoetin alfa-epbx) or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Aranesp.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 30, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on July 30, 2019.
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 enrollee was most recently hospitalized from 3/3/20 to 3/11/20 due to acute respiratory failure with hypoxia secondary to chronic obstructive pulmonary disease. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He tolerated dialysis. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a stand by assist to minimal assist level with functional mobility including gait to 150 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on April 23, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say thatthe physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order/lab requisition stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on April 23, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on August 9, 2019.
You asked the Plan to pay for the psychotherapy services. You say that you did not know that you needed prior authorization as you had been receiving therapy services before. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
The Plan must follow Medicare rules. Medicare rules say that a social worker is not eligible to participate in the Medicare program. We looked at the file and Medicare rules. The file shows that the psychotherapy services. A social worker is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on August 9, 2019.