Persius/hicric huggingface dataset:
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 you need inpatient rehabilitation because you are a high risk of falling and you need help performing routine activities. You need these services to regain function. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met, and you can receive the necessary care in another 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 in the Medicare rules section. 

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 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 on July 6, 2021 for treatment of sepsis secondary to a lumbar wound infection following recent lumbar laminectomy. There is no documentation provided indicating medical necessity for the requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. 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 copayments for arthrocentesis provided on March 26, 2021, and May 4, 2021.
You asked the Plan to waive the copayments for arthrocentesis. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 specialist visits. Your contract with the Plan also clearly says that you must pay a $275 copayment for outpatient hospital services. You received arthrocentesis at a specialists office on March 26, 2021. Therefore, you are responsible to pay the $25.
You received arthrocentesis at an outpatient hospital facility on May 4, 2021. Therefore, you are responsible to pay the $275 copayment. The total amount you owe is: $300. You have been asked to pay the total copayment amount of $300 for arthrocentesis. Arthrocentesis falls within the physician/practitioner services including doctor's office visits outpatient hospital 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 copayments for arthrocentesis provided on March 26, 2021, and May 4, 2021.
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 you need inpatient rehabilitation to recover fully. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in another 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 in the Medicare rules section. 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a wheelchair repair.
You asked the Plan to pre-approve a wheelchair repair. You say that the service is medically necessary. The Plan denied your request. The Plan says that this is not a covered 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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not included any citation or evidence as to why the requested repair would not be covered. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pre-approve a wheelchair repair.
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the annual wellness visit (G0439) rendered by an out-of-network (OON) provider on January 21, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. Enrollees do not need to get a referral or prior authorization when care is received from out-of-network providers. You are not a network provider with the Plan. However, the Plan contract states that enrollees can receive care from either a network provider or an out-of-network provider. Additionally, the enrollee does not need to get a referral or prior authorization for the service provided. Therefore, we decided that the Plan has to pay for the annual wellness visit (G0439) rendered by an out-of-network (OON) provider on January 21, 2021.
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 inpatient mental health services.
You asked the Plan to pre-approve inpatient mental health services. You say that the services were medically
necessary. The Plan denied your request. The Plan says services were denied due to untimely notification.
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 inpatient mental health services.
Our reviewer says that based upon review the records provided, the admission of this enrollee does not meet
the criteria for acute inpatient mental health treatment. Our physician reviewer found the enrollee was not
shown to be a danger to himself or others. The enrollee was without agitation or aggression and without
perceptual disturbance including auditory or visual hallucinations. 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.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health services have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient mental health services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nutrition evaluation and neuropsychological evaluation with a tertiary level provider.

You asked the Plan to pre-approve the tertiary level of care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says your information does not show that you require a tertiary level of care.

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 tertiary level of care. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no information within the records provided for review to necessitate that you initially received these services in a tertiary care setting. Rather your clinical presentation (based off the records provided) did not demonstrate any unique or extenuating needs that would require the extra specialization of a tertiary care center.

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 tertiary level of care have not been met. Therefore, we decided that the Plan does not have to pre-approve nutrition evaluation and neuropsychological evaluation with a tertiary level provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Device.
You asked the Plan to pre-approve the Vertiflex Superion Device. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says this device is experimental.
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 Vertiflex Superion Device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental and more research is needed to show its safety and efficacy. 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 Vertiflex Superion Device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a thoracoscopic MAZE procedure.

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 persistent atrial fibrillation refractory to medical treatment. The record does not indicate that the enrollee is undergoing open concomitant coronary artery bypass grafting and/or valve replacement or repair. The requested procedure 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 thoracoscopic MAZE procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep gum root cleaning of all 4 quadrants (D4341).

You asked the Plan to pre-approve gum cleaning. You say that you are appealing. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gum cleaning when the services are medically necessary and reasonable. 

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 gum cleaning. Our reviewer says that you do not meet the criteria for the requested dental services. Our physician reviewer found the periodontal charting indicates more than 4 areas of affected teeth per quadrant with pockets in the 3 to 5 millimeter range. The X-Rays show normal bone levels in the upper right, upper left, and lower right quadrants with no appreciable loss of attachment. The bone levels appear good around your existing implants. The lower left quadrant appears to have some slight bone loss around Teeth #18,19 and 20, which would be less than the required number of teeth in a quadrant to utilize code D4341 which is reserved for four or more teeth in a quadrant. There is a lesser code that can be utilized for the lower left quadrant which involves three teeth with attachment loss. The upper right, upper left, and lower right quadrants have not been shown to have any appreciable loss of bone/attachment and would not meet criteria for scaling and root planing, while the lower left quadrant does not meet criteria for four or more teeth. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of gum cleaning have not been met. Therefore, we decided that the Plan does not have to pre-approve deep gum root cleaning of all 4 quadrants (D4341).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with options.
You asked the Plan to pre-approve power wheelchair. You say that this wheelchair is required to be safe,
independent, and functional in the home. The Plan denied your request. The Plan says the denial of
authorization for this equipment is correct, because you are currently a resident in a skilled nursing facility and
a power wheelchair is never covered by Medicare's durable medical equipment (DME) benefits at this location.
The Plan must follow Medicare rules. Medicare rules say that DME such as a power wheelchair is not
separately covered when the enrollee is a patient in a skilled nursing facility.
We looked at the file and Medicare rules. You are currently a resident in a skilled nursing facility; therefore,
the Plan cannot separately cover the requested power wheelchair at this time. Based on this information, we
decided that Medicare rules for coverage of power wheelchair have not been met. Therefore, we decided that
the Plan does not have to pre-approve a group 3 power wheelchair with options.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than one hundred (100) feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you are a diabetic and are in need
of compression stockings, but you have to have a special order. The Plan denied your request. The Plan says
this item is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you have stabilized medically and have been
receiving skilled rehab services in an inpatient rehabilitation facility (IRF). You have tolerated inpatient rehab
services and continue to improve with daily skilled nursing and/or skilled therapy services. You could benefit
from continued services at the current level of care. You have made slow progress with therapy, there is no
indication that transfer to a SNF. You can continue to receive skilled rehab services at the current IRF or be
stepped down to a lower level of care when appropriate. There are no services offered at a SNF that are not
offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.