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

We decided that the Plan does not have to pre-approve the continuation of inpatient hospital care.

You asked the Plan to pre-approve the continuation of inpatient hospital care. You say that you are not ready for discharge. The Plan denied your request. The Plan says you can be safely discharged.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continuation of inpatient hospital care. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you were admitted to the current acute care facility requiring emergency hernia surgical repair. Your recovery has not been complicated and recent notes, show your vitals stable, you are able to eat, you are having bowel movements and urinating without issue, and you are tolerating oral medications and ambulating without assistance. Therefore, continued inpatient services are not supported in the record.

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 continuation of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient hospital care.
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 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 the LTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with hypoglycemic/hypoxic encephalopathy requiring mechanical ventilation, trach, and PEG tube placement. She appears to be stable but has failed weaning attempts and requires only additional short term acute care services which can safely be completed at the current facility. She does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that she requires that are not already available and covered at the current facility. The LTACh services are 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) for tooth # 14 provided on September 18, 2020.

You asked the Plan to pay for the dental service. You say that your copayment should be waived. You say that 1 tooth was covered at 50% for the crown but the other tooth was not covered at all. You say that you have not hit your maximum of $1,000 for the year so it should be covered at 50% like the other tooth. The Plan denied your request. The Plan says you received 1 crown on the date of service in this appeal. The Plan also says that you pay 50% for Class 3 Major Services, including crowns.

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, if a method of treatment is more costly than is customarily provided, benefits will be paid on the least costly method of treatment, and you will be responsible for the remaining balance. The record shows that the porcelain crown for tooth # 14 was paid at the alternative benefit of a porcelain crown fused to predominantly base metal. Therefore, we decided that the Plan does not have to pay more for the porcelain crown (D2740) for tooth # 14 provided on September 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Adempas 2.5mg tablet (J8499).

You asked the Plan to pre-approve Adempas 2.5mg tab. You say that the item is medically necessary. The Plan
denied your request. The Plan says the item is not covered under Part B Medicare prescription drugs.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Adempas 2.5mg tablet
(J8499).
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 IRF care is medically necessary. The Plan denied
your request. The Plan says admission to 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 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 complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the
patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Finally,
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 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 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. The enrollee was admitted for surgical repair of a right femur fracture. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that this service is medically necessary. The Plan denied your request. The Plan says that inpatient care is not medically necessary and care can be provided at observation level.

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 pre-approve 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 with the antibiotic treatment, the necessary wait for culture results, and the monitoring for delirium tremens, the hospital stay was expected to cross 2 midnights based on the provided 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve the acute inpatient hospital care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.

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 your 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray (CPT 76102) provided on July 20, 2018.

You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says the billed service cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 76102 is "Radiologic examination, complex motion (ie, hypercycloidal) body section (eg, mastoid polytomography), other than with urography; bilateral". 

We find that CPT code 76102 is not supported in the medical record. Specifically, the records provided do not show that imaging was provided on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray (CPT 76102) provided on July 20, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-ofnetwork
provider.

You asked the Plan to pre-approve the medical services. You say that you have already seen this provider and
they have been able to control your blood sugar level. The Plan denied your request. The Plan says there are innetwork
providers that can provide the services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the medical services to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that the enrollee cannot meet his needs at home
independently. The Plan denied your request. The Plan says there are no noted daily skilled nursing or therapy
needs.

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 physician reviewer
found that the enrollee does not have documented skilled nursing, or skilled therapy needs. He requires
maximal assistance for mobility and activities of daily living. Daily skilled services are not required to establish
a maintenance program, or to prevent deterioration of the enrollee's condition. His care needs at this point are
custodial.

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 a skilled nursing facility (SNF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you have no daily skilled nursing or therapy needs.

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 physician reviewer found that you are at a maximal assist level for bed mobility, and standby assist for grooming. The documentation does not support that skilled nursing or skilled therapy services require the specialized skills of a qualified nurse or therapist. Skilled services are not needed on a daily basis or as practical matter 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 2, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was
submitted after the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the services was not filed until October 19, 2020. This means that more than
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the
Plan does not have to pay for the services provided on October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter (E0118).

You asked the Plan to pre-approve a knee scooter. You say that this is necessary for you to avoid putting pressure on your foot. The Plan denied your request. The Plan says this is 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 pre-approve a knee scooter. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence in the documentation that you are unable to use your upper extremities and use crutches. 

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 knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the facet injections (CPT Code 64494 and 64493).

You asked the Plan to pre-approve the facet injections. You say that the services are necessary. The Plan
denied your request. The Plan says the services are not 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 facet injections. Our physician
reviewer found the medical records show that the enrollee has back pain radiating to the leg. There is no clear
documentation that the facet joint is the pain generator. Criteria for facet injection 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 the facet injections have not been met. Therefore, we decided that the Plan does
not have to pre-approve the facet injections (CPT Code 64494 and 64493).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, thorax; without contrast material (CPT Code 71250).

You asked the Plan to pre-approve the CT scan. You say that the scan is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

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 CT scan. Our physician reviewer found the most recent CT from 2020 showed that these nodules were, however, unchanged compared to 2014. Based on no significant change over at least six (6) years, additional CT surveillance is not required or warranted according to current guidelines. Therefore, this request for CT chest will be considered not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT, thorax; without contrast material (CPT Code 71250).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you cannot fully participate in physical therapy until you are weight bearing.

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 physician reviewer found that the documentation does not support that skilled nursing services with a skilled professional nurse is required to provide medically necessary treatment. You do not have complex wound care or other skilled nursing needs that requires a SNF stay. Your functional level, with weight bearing limitations, does not require skilled therapy services of a qualified therapist to provide medically necessary treatment only in a SNF. Skilled services are not needed on a daily basis or as practical matter in a SNF setting 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you received on May 19, 2020.

You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a covered
benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when provided during a routine exam.

We looked at the file and the Plan's rules. The Plan covers refractions provided during routine eye exams. The
requested refraction was not provided as part of a routine exam. Based on this information, we decided that the
Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have
to pay for the eye refraction you received on May 19, 2020.