Persius/hicric huggingface dataset:
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 IRF admission is medically necessary.The Plan denied your request. The Plan says your needs can be met at a different level of care.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 the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You mayrequire skilled physical therapy and occupational therapy but based on the medical records provided you do not require treatment in an intensive rehabilitation therapy program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approve SNF services. You say that the enrollee would benefit from rehab therapy based on her Huntington's diagnosis.The Plan denied your request. The Plan says SNF care exceeds the enrollee's medical 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 from a nursing perspective, you had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a modified independent level with bed mobility and transfers. She required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 skilled nursing facility (SNF) 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.You asked the Plan to pre-approve IRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can safely receive the services you need 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. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical management of femur fracture. All medical problems are stable and there are no complex nursing or rehabilitative needs. There is no documented need for ongoing acute inpatient care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While physical and occupational therapy are a reasonable part of the management of your condition, the records do not support a need for intensive rehabilitation services. There is no a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to reimburse you $106 for the filling provided on February 21, 2019. We decided that the Plan does not have to pay for the office visit provided on December 30, 2019. You asked the Plan to reimburse you for the  dental services and office visit. You say that you never received reimbursement for any services.The Plan says that the claims processed correctly.We decided that the Plan has to reimburse you $106 for the filling provided on February 21, 2019. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The Plan contract says that you only pay 50% coinsurance for a filling from an in-network provider. You have been asked to pay $150 for the filling. However, according to the contract you cannot be asked to pay more than $44, which is 50% of the allowed amount. Therefore, we decided that the Plan has to reimburse you $106 for the filling. We also decided that the Plan does not have to pay for the office visit provided on December 30, 2019.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 your deductible is $1,000, which applies to primary care physician visits.Therefore, we decided that the Plan does not have to pay for office visit.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: 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 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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While physical and occupational therapy are a reasonable part of the management of your condition, the records do not support a need for intensive rehabilitation services. There is not a reasonable expectation that you 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 pay for the acute inpatient hospital care provided from December 11, 2019 through December 12, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the documentation provided, this hospitalization does not qualify for inpatient payment under the two-midnight rule. At the time of admission, it was not reasonable to expect that two midnights in the hospital would be required. The emergency department (ED) evaluation showed no life/limb threatening condition(s). The enrollee could have been safely placed on observation status pending further monitoring/evaluation. That the enrollee left against medical advice (AMA) prior to receiving two midnights of care, has no bearing on the fact that the enrollee was stable enough to be placed on observation status in the first place.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 not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 11, 2019 through December 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on March 18, 2020.You asked the Plan to waive the copayment for the x-ray. You say that you should not be responsible for the x-ray because it was done as a post-op on a reverse total left should replacement. 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 $40 copayment for basic radiological services at an in-network specialist's office. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $40 copayment for the x-ray.You have been asked to pay a $30.81 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.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 the x-ray provided on March 18, 2020.Our decision is only about the March 18, 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary for the enrollee.The Plan denied your request. The Plan says that the enrollee is receiving appropriate care at the current acute care facility.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. The enrollee does not require services at the proposed LTACH that are not already available at the current acute care hospital. Based on the continued improvement, it is unlikely the enrollee will require at least 25 additional days of acute care services. Transfer to a lower level of care when more stable should be sufficient. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for nurse practitioner services provided on June 24, 2019.You asked the Plan to pay for the nurse practitioner services. You say that that the enrollee was seen by this provider during a hospital stay. The Plan denied your request. The Plan says that there is no authorization for this service.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The rules also say that a contract plan provider is an agent of the plan. Services and referrals obtained from a plan provider are viewed as plan-approved unless notice is given that the services will not be covered.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not submitted information to us with regard to the network status of the hospital where the services were provided to determine if the nurse practitioner services were Plan-directed care. Therefore, we decided that the Plan has to pay for the nurse practitioner services provided on June 24, 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: 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. The Plan denied your request. The Plan says the enrollee has not completed her full hospital course of 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 physician reviewer found that the enrollee was admitted to the acute hospital with a diagnosis of endocarditis and cerebral infarction due to thrombosis of precerebralartery. She continues to require inpatient level of care hospital services including diuresis with IV medication and continued IV antibiotics. She is receiving appropriate care at the present acute care facility. the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiogram provided on February 3, 2020.You asked the Plan to waive the copayment for the echocardiogram. You sent your bill in for review. 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 $25 copayment for basic radiological services at an in-network specialist's office. You have been asked to pay a $25 copayment for the echocardiogram. The echocardiogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the echocardiogram provided on February 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen.You asked the Plan to pre-approve Epogen. The Plan denied your request. The Plan says this drug is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Epogen. Our reviewer says that Epogen is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that the enrollee is noted to have diabetes, diabetic nephropathy and anemia. Recent laboratory studies show anemia and low-normal iron studies. The enrollee was only recently prescribed oral iron. The documentation does not show that the enrollee's iron deficiency has been adequately addressed and monitored. The documentation does not show any evaluation for other causes of anemia (B12 deficiency, GI bleeding). Therefore, the initiation of Epogen/Procrit is not shown to be currently medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epogen have not been met.Therefore, we decided that the Plan does not have to pre-approve Epogen.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nerve block injection provided on September 25, 2019.
You asked the Plan to waive the copayment for the nerve block injection. You say that you should not be responsible for copayment. 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 $375 copayment for each covered surgery performed as an outpatient at an in-network hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $375 copayment for the nerve block injection.
You have been asked to pay a $242.93 copayment for the nerve block injection. The nerve block injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 a nerve block injection provided on September 25, 2019.
Your complaint that you were dissatisfied with the provider and the service is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral
branches.
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. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain.
She had a diagnostic sacroiliac joint injection that achieved 100 percent pain relief for four hours and 60 to 70
percent pain relief for three to four days. The requested RFA of the lateral sacral branches is considered
experimental/investigational in nature due to wide variation in efficacy and is 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.