Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to doctor at provider, an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthe medical group has providers available who can manage these medical problems.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 Plandoes not haveto pre-approvea referral to doctor at provider, an out-of-network provider.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee does not need to participate in PT or OT five times per week - care can be handled in a less intensive setting.
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 is medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. The enrollee may benefit from further PT and OT, but does not require an intensive therapy program. IRF admission is not medically necessary, based on 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 admission to an inpatient rehabilitation facility (IRF).You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee can be taken care of at a lower 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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not require intensive physician or nursing supervision in an IRF. You may benefit from PT and OT but the documentation does not indicate that you require this therapy or can tolerate it on an intensive level 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional transportation mileage.You asked the Plan to pre-approveadditional transportation mileage. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says you requested 65 additional miles for a total of 115 miles per one-way trip. The Plan says that your transportation benefit only covered up to 50 miles per one-way trip.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 one-way transportation trips per year, not to exceed 50 miles per one-way trip. We looked at your request, the records in the case file, and the rules. The file shows you are requesting an additional 65 miles for a total of 115 miles per one-way trip. Your contract with the Plan clearly states that each one-way trip must not exceed 50 miles.Therefore, we decided that the Plan does not have to pre-approveadditional transportation mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an enclosed walker with a rear seat for the enrollee.
You asked the Plan to pre-approve the requested walker. You say that the enrollee cannot walk. The Plan denied your request. The Plan says the medical necessity for a walker with an enclosed frame has not been established. A standard walker will be covered if requested.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The rules say the requested walker is not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an enclosed walker with a rear seat for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that the requested shower seat is medically necessary for you. You say that you had a stroke and you need the seat to bathe safely.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicarerules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided thatthe Plan does not have to pre-approvea shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided on August 23, 2019.You asked the Plan to pay for inpatient services. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were inappropriately billed as inpatient services.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that the billing of these services as inpatient is not supported in the medical record. Specifically, the records show that the enrollee was never admitted as they left against medical advice at 7:01 PM on August 23, 2019. The inpatient order was not made until 7:18 PM, after the enrollee had already left. Based on this information, we decided that Medicare rules for coverage of inpatient services have not been met.Therefore, we decided that the Plan does not have to pay for inpatient services provided on August 23, 2019.
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 care can be provided at a lower level of care, such as subacute rehab.
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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power pressure-reducing air mattress. You asked the Plan to pre-approve these services. You say that the mattress will help prevent bed sores. The Plan denied your request. The Plan says the services are not medically necessary. The Plan must follow Medicare rules. Medicare rules say that a power pressure-reducing air mattress is covered when specific criteria are met. 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 enrollee does not meet the criteria for coverage. Our physician reviewer found the records do not show evidence of multiple stage II pressure ulcers on the trunk or pelvis or large or multiple stage III or IV pressure ulcers. The enrollee therefore does not meet the criteria for coverage of the requested mattress and it is 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power pressure-reducing air mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea knee orthosis (L1845). You asked the Plan to pre-approvethe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 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 orthosis. Our reviewer says that the documentation does not show that the orthoses is medically necessary. Our physician reviewer found the submitted documentation does not support a physical examination of knee instability. Without the supporting documentation, medical necessity is not determined. \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 orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvea knee orthosis (L1845).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveHydroxychloroquine 200mg tab.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysdrug coverage is limited to Medicare Part B covered drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveHydroxychloroquine 200mg tab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee has chronic systolic and diastolic heart failure as well as acute and chronic respiratory failure. You say that the enrollee's underlying health conditions make her a high fall risk and you recommend the shower chair to help her. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography (95811).
You asked the Plan to pre-approve polysomnography. You say that you need this study because you have been without a CPAP since 2013. The Plan denied your request. The Plan says a home sleep study would be more appropriate.
The Plan follows Medicare rules. Medicare rules say that sleep studies are covered according to the above guidelines when 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 polysomnography. Our reviewer says that the requested sleep study is not medically necessary. Our physician reviewer found a Sleep Study can be considered when a Home sleep study has been attempted and is negative, inconclusive, or technically inadequate (report submitted for review). An in lab Sleep Study can be considered when a home sleep study cannot be done due to one of the following reasons: obstructive sleep apnea symptoms with low pretest probability of obstructive sleep apnea or the patient does not have the mobility, dexterity or cognitive ability to
use the available equipment safely at home and the ability to follow instructions. In this case, there is no documentation that suggests that a home sleep study cannot be done. The review has determined that the enrollee's needs could be met with a different level of sleep study such as a home sleep study. The enrollee does not have comorbidities that preclude a home sleep study. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography (95811).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the adjustable bed frame and mattress purchased on November 4, 2019.
You asked the Plan to provide reimbursement for the adjustable bed frame and mattress. You say that you need to be able to sleep with your head elevated due to multiple medical issues. You feel that the network hospital beds were too expensive and would have required you to sleep separately from your wife. You believe that the plan should reimburse you since this was the best option for you. The Plan denied your request. The Plan says this claim/service lacks information or has submission/billing error(s).
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Although your medical condition may make this item useful to you, it is not a hospital bed which is primarily medical in nature. Therefore, we decided that the Plan does not have to provide reimbursement for the adjustable bed frame and mattress purchased on November 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the upper extremity.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show a failure to improve following a recent six-week trial of doctor-prescribed treatment.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found according to the Ortho note, you have impingement symptoms. There is no red flag to mandate immediate imaging. You have also stated that you desire conservative management initially. Physical therapy has not been ordered. Absent a six-week trial of PT, the medical necessity of this MRI has not been established. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the upper extremity.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTresiba for the enrollee.You asked the Plan to pre-approveTresiba. You say that there has been improvement with the use of Tresiba.The Plan denied your request. The Plan says this medication does not fall under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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-approveTresiba for the enrollee.Benefits for Tresibamay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee is with a past medical history of chronic kidney disease, asthma, atrial fibrillation and hypertension who has been hospitalized with acute respiratory failure due to COVID-19 infection and pneumonia. She has been treated with antibiotics and hydroxychloroquine and has improved - she still remains on nasal canula oxygen and is weak and deconditioned. She is on Lasix, atenolol, aspirin and Eliquis. She is requiring minimum to moderate assistance with most activities of daily living and is walking about 50 feet with a walker. Her therapy sessions are limited by generalized weakness, decreased endurance and compromised respiratory status. Transfer to an acute inpatient rehabilitation facility is requested. Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Treatment in a skilled nursing facility with nursing, physical and occupational therapy appears to be more appropriate for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation provided on July 16, 2019.You asked the Plan to pay for ambulance transportation. You say that this was medically necessary.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this ambulance transportation was not medically required for you.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. 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 ambulance transportation. Our reviewer says that this service does not meet the Medicare criteria for coverage. Our physician reviewer found transportation via ambulance to the emergency department was not medically necessary. You did not require the expertise of trained personnel or the equipment available only on an ambulance in order to provide safe transportation. Transportation could have been provided by other means without endangering your condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transportation have not been met.Therefore, we decided that the Plan does not have to pay forambulance transportation provided on July 16, 2019