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 these services are medically necessary. The Plan denied your request. The Plan says that 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 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a hip fracture after a fall. Your medical conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that 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: SNF
Decision: Favorable

We decided that the Plan has to waive the copayment for the SNF stay.

You asked the Plan to waive the copayment for the SNF stay. You say that you should not have to pay a
copayment because you were ready to be discharged. You say you were not given the option to
leave earlier. The Plan denied your request. The Plan says that you have been charged less than the standard
amount.

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. The Plan did not submit the correct Evidence of Coverage. Therefore, the plan
has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan
contract. Therefore, we decided that the Plan has to waive the copayment for the SNF stay.

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 for the enrollee.

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 the enrollee can safely receive the services needed 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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for dizziness, weakness, and anemia. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the enteral feeding supplies (B4150, B9002, E0776, B4035) provided on June 8, 2020. 

You asked the Plan to pay for the enteral feeding supplies. You say that you would like reconsideration because this is an outpatient claim and the codes are covered in the Medicare fee schedule. The Plan denied your request. The Plan says that this claim processed correctly.

The Plan must follow Medicare rules. Medicare rules say that prosthetic devices may be billed by the SNF or the rendering provider or supplier under an arrangement with the SNF. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the enteral feeding supplies have been met. Additionally, the Plan has not provided sufficient information to substantiate as to why these services are non-covered. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for the enteral feeding supplies (B4150, B9002, E0776, B4035) provided on June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reclining chair with electric lift for the enrollee.

You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this service is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above 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 the item. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the documentation does not indicate that the enrollee has a severe arthritis of the hip and/or a neuromuscular disease. The seat lift is not likely to effect improvement in the enrollee's condition; or arrest or retard deterioration in the enrollee's condition. The records are not clear about whether the enrollee is completely incapable of standing from a chair in the home from the findings on an objective physical exam. The records indicate that the enrollee has difficulty walking, and muscle weakness prevents walking requiring a wheelchair for mobility. 

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 item have not been met. Therefore, we decided that the Plan does not have to pre-approve a reclining chair with electric lift for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for targeted genomic sequence analysis panel solid organ or hematolymphoid neoplasm DNA and RNA analysis when performed 51 or greater genes (CPT 81455).

You asked the Plan to pre-approve genomic sequencing genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that genetic testing is only covered for certain indications.

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 genomic sequencing genetic testing. Our reviewer says that the documentation does not support that the requested genetic testing is medically reasonable and necessary. Our physician reviewer found the enrollee has has mild bibasilar lung opacities and hilar adenopathy. The enrollee's bronchoalveolar lavage was negative for malignancy. Surgery was recommended.

The documentation does not support that the coverage criteria for the requested genetic testing were met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genomic sequencing genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing for targeted genomic sequence analysis panel solid organ or hematolymphoid neoplasm DNA and RNA analysis when performed 51 or greater genes (CPT 81455).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutments and abutment-supported porcelain fused to metal crowns.

You asked the Plan to pre-approve these services. You say that you were not aware that the services wouldn't be covered. The Plan denied your request. The Plan says the 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutments and abutment-supported porcelain fused to metal crowns.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amnioband or guardian, per square centimeter (CPT Code Q4151).

You asked the Plan to pre-approve the skin graft. You say that the skin graft services are necessary. The Plan denied your request. The Plan says the clinical information received for appeal did not establish medical necessity for a different type of skin graft for the your right leg.

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 skin graft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the fact that you had failed a graft in the past and that there insufficient support for repeating grafting regardless of type or thickness due to obesity and uncontrolled diabetes, this request for skin graft will be considered not medically necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skin graft have not been met. Therefore, we decided that the Plan does not have to pre-approve amnioband or guardian, per square centimeter (CPT Code Q4151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with an endodontist.

You asked the Plan to pre-approve a consultation with an endodontist. You say that you need this service because you are unable to chew food. The Plan denied your request. The Plan says this service is 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a consultation with an endodontist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care from February 19, 2021,
forward.

You asked the Plan to pre-approve inpatient mental health 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 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 care. Our
physician reviewer found you did not appear to require inpatient mental health treatment beyond the date in
question as you were not a danger to yourself or others, no auditory hallucinations or visual hallucinations
while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date
in question. It did not appear that the services were reasonably expected to improve your condition or for the
purpose of diagnosis beyond the date in question. You were treated under an individualized treatment plan
found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon
review the records provided for the admission, you did not meet the criteria for continued acute inpatient
mental health treatment for the dates in question of February 19, 2021, forward as you were not shown to be a
danger to yourself or others. You were not showing any auditory or visual hallucinations and was
cooperative/compliant with treatment. You were not showing any aggressive behaviors, or any treatment
required for acute threats of safety and not showing any withdrawal symptoms or signs, seizures etc. 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 care have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient mental health care from February 19, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard.

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 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve portable oxygen concentrator, Inogen 5, (E1392) and nasal cannula (A4615).

You asked the Plan to pre-approve portable oxygen concentrator and nasal cannula. You say that the portable oxygen concentrator you have is not the right one. The Plan denied your request. The Plan says the item is not medically necessary for you because the Plan provided you with a portable oxygen concentrator on December 3, 2019, which is considered appropriate for your respiratory condition.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you have portable oxygen concentrator and oxygen tank. Portable oxygen concentrator and oxygen tank serves the same purpose as Inogen 5 and nasal cannula. Specifically, the item requested is considered a duplicate and is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve portable oxygen concentrator, Inogen 5, (E1392) and nasal cannula (A4615).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the magnetic resonance imaging (MRI) scan of pelvis before and after contrast (72197) provided October 5, 2020.

You asked the Plan to waive the deductible for the MRI scan of pelvis. You say that you were unaware of the deductible. The Plan denied your request. The Plan says the deductible had not been met when these services were rendered.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for radiological diagnostic services. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category radiological diagnostic services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for radiological diagnostic services. This cost sharing is a contractual obligation that had not been met at the time the MRI scan of pelvis was received on October 5, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the magnetic resonance imaging (MRI) scan of pelvis before and after contrast (72197) provided October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0651, E0667) provided October 1, 2020.

You asked the Plan to pay for the pneumatic compression device. You say that the device was medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

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 the pneumatic compression device. Our reviewer says that the device was not medically necessary. Our physician reviewer found documentation indicates that on physical exam, the enrollee has 2+ lower extremity edema, but no ulcers. The review indicates that the records do not support medical necessity for the provided device. 

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 pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0651, E0667) provided October 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. 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 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 there is no documentation provided necessitating admission to a LTACH. 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 the enrollee 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 LTACH services.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six rolls of waterproof tape.

You asked the Plan to pre-approve the rolls. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no wound.

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. Therefore, we
decided that the Plan does not have to pre-approve six rolls of waterproof tape.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter for the enrollee.

You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria was not met.

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 scooter. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation per the 11/15/20 DME evaluation does not reveal that the enrollee's mobility deficit impairs participation in MRADLs in the home. The mobility deficit is also helped effectively by a walker. 

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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter for the enrollee.