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 the enrollee needs intensive rehabilitation with daily
physician management and 24-hour specialized rehabilitation nursing. You say that the enrollee's complex
needs cannot be met with home health because she is staying with elderly relatives that cannot care for her. The
Plan denied your request. The Plan says the guidelines for coverage have not been met. 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 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of an ankle fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary 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. 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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the records provided support the need for care in an IRF. 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 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 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The enrollee was admitted for hemicolectomy for colon cancer. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 this enrollee 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that SNF care is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for skilled care as she does not require at least 1 hour of daily of continuous skilled nursing care. The enrollee is not participating in therapy and the physician did not order the admission to the skilled facility.
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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on review of the available records, the enrollee does not meet the CMS coverage criteria for an admission to a SNF. The enrollee is medically stable. The enrollee has no skilled nursing needs. Functionally, she does not require daily skilled therapy services on an inpatient basis in a SNF at her current level of function. She is not anticipated to progress further. SNF admission is not medically necessary. Her rehabilitation needs can be safely provided at an alternate level of care with infrequent therapies as needed. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services.
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the SNF services are medically necessary. The Plan denied your request. The Plan says there are no daily skilled nursing or therapy needs at this time.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152, 99153) provided on April 30, 2020.
You asked the Plan to pay for sedation services. You say that this is supported by the records. The Plan denied your request. The Plan says these codes are not documented.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. The definition of 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports,
requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service). We find that CPT codes 99152 and 99153 are not supported in the medical record. Specifically, the records do not document the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99152, 99153) provided on April 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement flex-walk system and multiaxial ankle with swing phase active dorsiflexion feature.
You asked the Plan to pre-approve replacement; all lower extremity prostheses, flex-walk system or equal (L5981) and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968). You say that you would like the additions approved. The Plan denied your request. The Plan says the current foot is still under warranty.
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 replacement; all lower extremity prostheses, flex-walk system or equal (L5981) and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968). Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the member appears to be a K3 ambulator but has recently been given a new prosthesis (March 2020). This prosthesis is documented as still under warranty. The documentation doesn't clearly indicate why a new system is required instead of repairing the existing prosthesis. The requested prosthesis 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 replacement; all lower extremity prostheses, flex-walk system or equal (L5981) and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement flex-walk system and multiaxial ankle with swing phase active dorsiflexion feature
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve 25mg/ml Keytruda Intravenous Solution.

You asked the Plan to pre-approve the Keytruda. You say that you would like reconsideration because the Keytruda is medically necessary. The Plan denied your request. The Plan says that the information does not show that the cancer tested positive for PD-L1.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Keytruda. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found Pebrolizumab (Keytruda) is FDA approved as first-line, single-agent treatment of non-small cell lung cancer (NSCLC) in patients with stage III NSCLC (who are not candidates for surgical resection or definitive chemoradiation) or in patients with metastatic NSCLC, and with tumors with PD-L1 expression (tumor proportion score [TPS] =1%), as determined by an approved test, and with no epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) genomic tumor aberrations. this member meets this criteria. 

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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 25mg/ml Keytruda Intravenous Solution.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health skilled nursing visits (G0299).

You asked the Plan to pre-approve the home health skilled nursing visits. You say that you would like reconsideration because the continued skilled nursing services are medically necessary. The Plan denied your request. The Plan says the records do not support the need for a skilled nurse to make more visits.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.

A doctor must certify the need for home health care services. 

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 home health skilled nursing visits. Our reviewer says that the requested, ongoing, home health skilled nursing services are not shown to be medically necessary and reasonable. Our physician reviewer found the enrollee does not have documented skilled nursing 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 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the home health skilled nursing visits (G0299).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of skilled nursing facility (SNF) services provided from January 23, 2021, through February 21, 2021.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says continuation of SNF services 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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that at the time of admission, the enrollee required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of January 23, 2021 the enrollee did not require any skilled nursing or rehabilitation services on a daily basis. The enrollee was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of January 23, 2021. He did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved; however, his function had plateaued by January 23, 2021 and he did not require any further inpatient skilled rehabilitation services. The enrollee's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. As of January 23, 2021 the enrollee required custodial services. The denial for further inpatient skilled care is upheld. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from January 23, 2021, through February 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Pure Wick Catheter System (E1399). 
 
You asked the Plan to pre-approve external catheter system. You say that the enrollee has extenuating 
circumstances necessitating the external catheter system. The Plan denied your request. The Plan says the 
Medicare criteria for coverage are not met. 
 
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. Additionally, Medicare rules say that providers must report services correctly. Providers must report services 
with the appropriate CPT code. In this case, the CPT Code Manual definition of code a Pure Wick female 
external catheter system is A9270 not E1399, which is the 'unspecified' code. Based on both of these factors 
together, we decided that the Plan does not have to pre-approve a Pure Wick Catheter System (E1399).
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 stable and suitable for transfer to an LTACH. You say that the admission to an LTACH is indicated by the enrollee's requirement of aggressive therapy and close physical monitoring. The Plan denied your request. The Plan says the clinical information provided shows that the enrollee's needs can safely be met in the current hospital setting. The Plan says that once the enrollee's doctor decides he is medically stable, he can safely receive the services needed in other settings.

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 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 he 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: 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 had a bad experience at the SNF in the past. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the records show the enrollee's medical conditions have improved and that care can safely be received in a less intensive setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for urinary tract infection, hypotension and hyponatremia. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary 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. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 8, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 19303 is not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid. In this case, the MUE for CPT code 19303 is 1. You billed 2 units of this code, exceeding the MUE. 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 pay for the surgical services rendered on February 8, 2021.