Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on October 22, 2019 with procedure codes 81406 and 81408. You asked the Plan to pay for genetic tests. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not covered for the enrollee's condition. 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 pay for genetic tests. 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 documentation submitted, there is no evidence that the services provided were medically necessary and reasonable to diagnose, treat, or otherwise manage the enrollee's condition(s). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic tests have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on October 22, 2019 with procedure codes 81406 and 81408.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT).You asked the Plan to pre-approve the IGRT. You say that the records provided support the need for IGRT.The Plan denied your request. The Plan says the type of treatment requested is not supported for the type of cancer the enrollee has.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 IGRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, IGRT is being used as routine practice. There does not seem to be any exceptional circumstances with the enrollee which necessitates the need for IGRT.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 IGRT have not been met.Therefore, we decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone replacement graft for ridge preservation, retrograde filling, and apicoectomy.You asked the Plan to pre-approve the bone replacement graft, retrograde filling, and apicoectomy. You say that you have an infection and if it is not fixed it could affect your heart.The Plan denied your request. The Plan says these services are not covered benefits.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 the bone replacement graft for ridge preservation, retrograde filling, and apicoectomy.
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 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 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on May 19, 2020 with critical illness myopathy with recent diagnosis and right lower lobe adenocarcinoma. He underwent right video-assisted thoracotomy and right lower lobectomy. He was transferred to the intensive care unit on June 2, 2020. He is medically stable with all stable comorbid conditions. There is no evidence of need for supervision by physical medicine and rehabilitation or acute rehab nursing care. He may benefit from further therapy but does not require an intensive therapy program 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 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 care could be received 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 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR, outpatient rehabilitation).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: 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. The Plan must follow Medicare rules. The rules say that 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 currently undergoing treatment at an acute care hospital (ACH) for a hepatic abscess. The enrollee had a drain placed and a chest tube placed. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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: 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 enrollee is not doing well in the hospital and
would benefit from admission to the IRF. The Plan denied your request. The Plan says the guidelines for
coverage of IRF care have not been met. The Plan says that an alternate setting could provide the care required.
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 does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stab phlebectomy.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 stab phlebectomy 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 services are not medically necessary. Our physician reviewer found it is not possible to attribute the enrollee's leg pain to her varicose veins based on the submitted records. There is no assessment of lower extremity arterial perfusion. There does not appear to be an assessment of lower extremity perfusion in the vein care provider's assessment. There is no documentation that the endovenous occlusion techniques are not feasible. The requested stab phlebectomy is therefore 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 stab phlebectomy.
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 is not doing well being in the hospital. You say that the enrollee would benefit from LTACH care.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive care in another setting.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 currently undergoing treatment at an acute care hospital (ACH) following a cardiac arrest.  The enrollee was intubated/ventilated and subsequently received a tracheotomy.  The enrollee has since been weaned from the ventilator.  There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such a time that no acute services are required.  The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care.You asked the Plan to pre-approve continued inpatient mental health care. You say that this treatment is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for continued inpatient care are not met.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 reviewer says that Medicare coverage criteria are not met. Our physician reviewer states the medical records show you were admitted to the acute inpatient psychiatric hospitalization on June 8, 2020 with Paranoid Schizophrenia, Cocaine Use Disorder, Severe, Alcohol Use Disorder, Severe and Cannabis Use Disorder Mild. You were recently hospitalized on May 29, 2020 until June 5, 2024 for psychosis, auditory hallucinations, poor sleep cocaine use, occasional cannabis use and alcohol use. You were complaining of auditory and visual hallucinations along with command hallucinations. The Plan covered your care from June 8, 2020 until June 9, 2020 but has denied further coverage based on medical necessity from June 10, 2020 forward claiming that you do not meet the level of care criteria for an acute inpatient psychiatric hospitalization but can be treated in a lesser restrictive setting.Based on the records provided, the Plan is correct. You do not meet the criteria required for inpatient mental health care as of June 10, 2020. 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 continued inpatient mental health care.
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 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 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 services are not medically necessary. Our physician reviewer found the enrollee had a stroke with resulting partial paralysis and impaired mobility. He now has difficulty swallowing and left-sided weakness. He is medically stable and needs mostly modified to maximum assistance for care. He does not have complex medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from further therapy but does not require an intensive therapy program 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-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. 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 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 services are not medically necessary. Our physician reviewer found the enrollee underwent an outpatient right total knee arthroplasty on June 1, 2020. Post-operative complications included no flow in the left anterior tibial, posterior tibial or dorsalis pedis, which was a change from the pre-operative status. He was transferred to a higher level facility on June 2, 2020. He is now medically stable with pain controlled. He has no evidence of need for supervision by acute physical medicine and rehabilitation or acute rehab nursing. He may benefit from further therapy but does not require an intensive therapy program 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rosuvastatin calcium 20mg tab.
You asked the Plan to pre-approve Rosuvastatin calcium 20mg tab. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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-approve Rosuvastatin calcium 20mg tab.
Benefits for Rosuvastatin calcium 20mg tab may 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis ophthalmic solution.You asked the Plan to pre-approve Restasis. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription 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 Plan does not have to pre-approve Restasis ophthalmic solution.Benefits for Restasis may 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea backyard pool.You asked the Plan to pre-approvea pool. You say that you have to keep moving to keep the pain away.The Plan denied your request. The Plan says the requested item does not meet the definition of durable medical equipment.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-approvea backyard pool.
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 IRF care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Medicare coverage criteria are not 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 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.