Persius/hicric huggingface dataset:
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 you just had lung cancer surgery and need as much rehabilitation as you can. 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 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 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 right upper lobectomy and right lower lobe wedge resection for lung cancer. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on February 18, 2021.
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you are retired and live on a fixed income. You say that you need help reducing the cost. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B chemotherapy drugs, associated administration services and all other Medicare Part B drugs. You have been asked to pay $272.04, which is 20% of the allowed amount for the denosumab injection provided on February 18, 2021. The allowed amount is $1,360.20 (20% x $1,360.20 =$272.04). The denosumab injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the denosumab injection provided on February 18, 2021.
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 the enrollee exceeds the Medicare criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to receive acute care services that have not been denied. The record does not indicate that the enrollee requires services at the LTACH that he is not currently receiving. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel represented by code 81455 provided on January 27, 2021.
You asked the Plan to pay for code 81455. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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. Medicare says that genetic testing submitted under code 81455 will be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis panel represented by code 81455 provided on January 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on
May 28, 2020.
You asked the Plan to pay for code 97110. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that code 97110 is not supported in the medical record. Specifically, the records indicate that the
services were performed by a physical therapist assistant in a home health or hospice setting. There is a more
appropriate code for the billed services provided in a home health setting. Therefore, we decided that the Plan
does not have to pay for the therapy services represented by code 97110 provided on May 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve LTACH services. You say that this transfer is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 72-year-old male who was admitted to the current acute care hospital with probable sepsis, cardiac arrest, severe pulmonary hypertension, lactic acidosis, severe hypotension, and ESRD requiring hemodialysis and mechanical ventilation support. He was diagnosed with DVT and required trach and PEG due to continued dependence on ventilation support. He was also diagnosed with C. Diff colitis and right heel wet gangrene requiring wound vac and antibiotics as well as a rectal tube. Poor prognosis is stated in the recent records.
The enrollee appears to be worsening and unstable requiring additional short-term acute care services which can be safely administered at the current facility until more stability is seen or a more permanent placement is decided. The enrollee does not require services at the LTACH that the enrollee is not already receiving at the current facility.
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 transfer to a long-term acute care hospital (LTACH) for the enrollee.
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 inpatient rehabilitation would be more beneficial to this enrollee than a lower level of care. The enrollee's prior level of function was completely independent, and they do not want to go to a nursing home. The Plan denied your request. The Plan says criteria for admission to an IRF are not met. The enrollee's medical needs are not complex. The enrollee likely is able to participate in an intensive therapy program; however, the necessary rehabilitation can be provided at a skilled nursing facility with the goal of safely returning the enrollee home.
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 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 does require physical and occupational therapy, but there is no documented 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. Medically necessary services can be provided in a different 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 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on August 6, 2020.
You asked the Plan to pay for code 97110. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that code 97110 is not supported in the medical record. Specifically, the records indicate that the services were performed by a physical therapist assistant in a home health or hospice setting. There is a more appropriate code for the billed services provided in a home health setting. Therefore, we decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on August 6, 2020.
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 enrollee would be best served with inpatient rehabilitation to expedite his return home. The Plan denied your request. The Plan says 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's nursing and therapy needs can be safely met 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 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 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 does require physical and occupational therapy, but there is no documented 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. Medically necessary services can be provided in a different 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 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on June 1, 2020.
You asked the Plan to pay for code 97110. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that code 97110 is not supported in the medical record. Specifically, the records indicate that the services were performed by a physical therapist assistant in a home health or hospice setting. There is a more appropriate code for the billed services provided in a home health setting. Therefore, we decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
You asked the Plan to pre-approve SI RFA. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for this service is correct, because there is poor
evidence to support the use of radiofrequency ablation for sacroiliac joint pain.
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 SI RFA. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this is considered an experimental/investigational procedure because of the wide variation in
efficacy reported in the literature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SI RFA have not been met. Therefore, we decided that the Plan does not have to
pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
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 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 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. The patient was admitted for weakness, back pain, and a fall after recent lumbar laminectomy. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extractions (D7210 x3), and unspecified preventive
procedures (D1999 x3) provided on August 3, 2020.
You asked the Plan to pay for extractions, and unspecified preventive procedures. You say that you were
unaware that the provider had opted out of Medicare. The Plan denied your request. The Plan says you are
responsible for services provided by privately contracted providers. The Plan will not reimburse for charges
incurred by Medicare Opt Out providers.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of extractions, and unspecified preventive procedures have not been met. Specifically, services were
provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out
provider. Therefore, we decided that the Plan does not have to pay for extractions (D7210 x3), and unspecified
preventive procedures (D1999 x3) provided on August 3, 2020.
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 an IRF is necessary for you to regain your prior level of function and achieve the best recovery. The Plan denied your request. The Plan says criteria for admission to an IRF have not been met. Your ongoing skilled therapy and nursing needs can be provided 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 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. You do require physical and occupational therapy, but there is no documented need for an intensive 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. Medically necessary services can be provided in a different 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epoetin Injection (J0887).
You asked the Plan to pre-approve Epoetin Injection, epoetin beta, 1 microgram, (for esrd on dialysis) (J0887).
You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says the
enrollee has not first tried and failed Aranesp.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Epoetin Injection, epoetin beta, 1
microgram, (for esrd on dialysis) (J0887). Our reviewer says that the drug is not medically reasonable and
necessary. Our physician reviewer found there is no evidence that the enrollee is allergic to or intolerant of
Aranesp. There is no evidence that the enrollee has tried and not responded to Aranesp. There is no
documentation as to why Aranesp would not be expected to be safe and effective for the enrollee. Therefore,
the requested Mircera is not shown to be currently medically necessary and 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 Epoetin Injection, epoetin beta, 1 microgram, (for esrd on dialysis) (J0887) have
not been met. Therefore, we decided that the Plan does not have to pre-approve Epoetin Injection (J0887).