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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
 
You asked the Plan to pre-approve SNF care. You say that the member has been going through therapy but has not been healing and making as much progress. The member requires more physical therapy before returning home. The Plan denied your request. The Plan says the member was no longer requiring any skilled nursing services as the only service he was receiving was a daily Lovenox injection which could be done at home by the member or a visiting nurse. He does not need daily PT nor to remain in a skilled nursing facility to receive additional physical therapy as he can receive any PT at home to transition to the home environment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary had stable vital signs. The beneficiary received PT in the SNF. By the dates in question, the beneficiary was at a supervision to contact the guard level with functional mobility including gait up to 60 feet with a rolling walker. He could negotiate 5 stairs with contact guard assist and bilateral rails. The reviewer has determined that the enrollee did not require skilled nursing services. There were no identifiable skilled nursing service needs, nor does the beneficiary require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the current medical condition and needs can continue to be met at the hospital.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support and oxygen supplementation, telemetry monitoring, surveillance laboratory studies, intravenous antibiotics, sacral wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER on April 16, 2019. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency care 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 copayment for an ER on April 16, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department visit, and the left hand x-ray provided on August 2, 2019.You asked the Plan to pay forthe outpatient hospital services. You say that the enrollee was brought to the hospital against the advice of the provider. You also say the services were not related to the hospice diagnosis.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe emergency department visit, and the left hand x-ray provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does nothave to pre-approvean office visit (99203) to be provided by the out of network provider.You asked the Plan to pre-approvean office visit. You say that you have been under the care of the provider from 2014. The provider performed an emergency endoscopic procedure as a result of a complication due to cholecystectomy. You'vehad several proceduresrendered by the provider and would like to continue being under his care. Someone from a medical group confirmed that the provider is part of the group but not a preferred doctor.The Plan denied your request. The Plan says members must receive care from a network provider and in most cases, care received from anout-of-network provider (a provider who is not part of our plan's network) will not be covered, except for the following: emergency care or urgently needed servicesand needed medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care (authorization is required).Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. A search was conducted and the record showsthat the provider isnotpart of the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvean office visit (99203) to be provided by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe immediate partial mandibular denture (D5222) provided on November 25, 2019.You asked the Plan to pay forthe dental service. You say that you fell on November 11, 2019 and lost your 4 front teeth. You say that you went to the emergency room. You say that you were in a lot of pain and wanted to get your teeth fixed so you went to provider. You also say that you were not aware of the authorization process that was required.The Plan denied your request. The Plan says immediate partial dentures are not listed as a covered service.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 and dentures are a covered service, immediate partial dentures, specifically, are not listed as a covered service.Therefore, we decided that the Plan does not have to payforthe immediate partial mandibular denture (D5222) provided on November 25, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forClopidogreltablets (self-administered drugs) provided on June 6, 2019.You asked the Plan to pay forself-administered drugs. You say that you do not remember being given this drug, and feel that being billed for this medication isunfair.The Plan denied your request. The Plan says the denial of payment for these drugs is correct, because these drugs are not covered by Medicare Part B and the Plan does not administer your Medicare Part D prescription drug benefits.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 pay forClopidogrel tablets (self-administered drugs) provided on June 6, 2019.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to provider for endoscopic spinal surgery.You asked the Plan to pre-approve the referral. You say that this is medically necessary, as the plan does not offer the minimally invasive endoscopic surgery.The Plan denied your request. The Plan says the care is available in-plan, and it is not within standard guidelines to perform endoscopic surgery for this unique scenario.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 referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found endoscopic spinal surgery is experimental. The open procedure may be safely done in plan and is most appropriate standard of care option.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 referral have not been met.Therefore, we decided that the Plan does not have to pre-approve a referral to provider for endoscopic spinal surgery.
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 records provided support the need for LTACH care. The Plan denied your request.
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 inpatient  with word finding difficulty and altered mental status. Computed tomography (CT) provided at that time showed no new acute process. The enrollee was going to discharge to a rehab facility and became increasingly lethargic and altered. A repeat CT showed new onset right MCA distribution infarct. The enrollee required intubation for airway protection. The enrollee has failed multiple ventilator weaning attempts and had trach and peg placed on December 17, 2019. The enrollee has currently been weaned to humidified T-piece, but there is no facility that will take her until trach has matured (30 days). There is no documentation provided necessitating admission to a LTACH. The enrollee continues to require acute hospital level of care services and is receiving appropriate care at the present acute care facility. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral.
You asked the Plan to pre-approve an out-of-network referral. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan states you can receive a second opinion, which is among the nation's leading cancer research institutions and one of only 50 comprehensive cancer centers designated by the National Cancer Institute. The Plan states that there are also 105 Oncology/Hematology Specialists available to you.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an inpatient hospital stay provided from September 17, 2019 to September 27, 2019.
You asked the Plan to pay for an inpatient hospital stay. The admission was warranted and supported by clinical documentation in the medical record. The Plan denied your request. The Plan says that based on the clinical records provided, the participant's care did not meet medical necessity criteria for acute inpatient hospital level of care. The participant's care needs could have been provided in an alternative care level such as observation status or acute nursing facility. A short period of observation care and the participant could have returned home to a nursing facility or to a sub-acute nursing facility or long-term nursing care (the participant's PACE interdisciplinary team) for out-patient observation and continued medical management.
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status. 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 an inpatient hospital stay. Our reviewer says that the service was medically necessary. Our physician reviewer found the enrollee presented with mental status changes. She was diagnosed with a urinary tract infection (UTI), aspiration pneumonia and sepsis. She was treated with intravenous fluids and intravenous antibiotics. The documentation supports that the requested services were necessary and reasonable to meet the participant's needs and to improve and maintain the participant's overall health status. The requested services were not experimental, and the requested services were not cosmetic. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient hospital stay have been met. Therefore, we decided that the Plan has to pay for an inpatient hospital stay provided  from September 17, 2019 to September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the WalkAide System.
You asked the Plan to pre-approve the WalkAide System. You say that the services are medically necessary.
The Plan denied your request. The Plan says the Medicare rules have not been 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 WalkAide System. Our physician
reviewer found Medicare's NCD for NMES has not been met for the Walk Aide device. The patient has a foot
drop from stroke. The patient does not have a non-neurological reason for disuse atrophy or have a spinal cord
injury.
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 WalkAide System have not been met. Therefore, we decided that the Plan
does not have to pre-approve the WalkAide System.
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 the enrollee requires this level of care.The Plan denied your request. The Plan says that this request exceeds the enrollee's needs.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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.You asked the Plan to pre-approve routine transportation. You say that you attend dialysis 3 days per week, and it is imperative that you have transportation to obtain these services.The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 60 one-way trips per calendar year is not covered by the Plan.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on December 10, 2019.
You asked the Plan to pay for the resin-based composite. You say that you received reimbursements for services completed by this same provider in the past. You also say that the dentist office indicated that nothing changed on their end. The Plan denied your request. The Plan says this service is not a covered benefit.
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 pay for the resin-based composite provided on December 10, 2019.
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. The Plan denied your request. The Plan says that you can safely receive the services you need 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. You were medically stable with no evidence of need for supervision by physical medicine and rehab physician or need acute rehab nursing care. Functionally you still need assistance. You may benefit from further physical therapy and an occupational therapy but do not require an intensive therapy program. 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.