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 you need IRF care to manage your condition. The Plan denied your request. The Plan says rules for IRF care have 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that you were admitted for back pain and has been discharged home with home health services. Medical conditions are stable. There are no complex nursing or rehabilitation needs.
In this case, you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Although you do require physical and occupational therapy. there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit for the evaluation and management of a new
patient (99204) provided on February 2, 2021.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because this service
was rendered by a separate provider and should be paid. The Plan denied your request. The Plan says this
service is denied because "new patient" qualifications have not been met.
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 99204 is office or other outpatient visit for the evaluation
and management of a new patient, which requires a medically appropriate history and/or examination and
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is
spent on the date of the encounter.
We find that CPT code 99204 is not supported in the record. Specifically, CPT code 99204 is used for new
patients. The record indicates that the member received services from the same provider on December 18,
2020. This means that the interpretation of "new patient" has not been met. There is a more appropriate CPT
code for the services rendered. Based on this information, we decided that Medicare rules for coverage of the
office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit for
the evaluation and management of a new patient (99204) provided on February 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four Famotidine injections (S0028 x4).
You asked the Plan to pre-approve the Famotidine injections. You say that it is imperative that you restart this
therapy. The Plan denied your request. The Plan says this medication is not deemed medically necessary.
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 Famotidine injections. Our reviewer
says that Famotidine injections are not medically reasonable and necessary for the enrollee. Our physician
reviewer found the provided documentation does not provide sufficient support for injectable Famotidine.
There was no reported diagnosis or clinical scenario which would justify this form of this medication. Our
reviewer found that no intolerance to oral medications were described. Our physician reviewer also found that
there was report of prior use of this medication; however, there was no documentation supporting that it was
safe and effective for you.
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 Famotidine injections have not been met. Therefore, we decided that the
Plan does not have to pre-approve four Famotidine injections (S0028 x4).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) lumbar spine
(72141) to be provided by an OON provider.
You asked the Plan to pre-approve the MRI. You say that this enrollee has a Boston Scientific pacemaker
which is not MRI compatible at your facility. Unfortunately, you are not able to scan these patients and need to
go out of network. The Plan denied your request. The Plan says enrollee's must receive their medical services
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with
non-contracted providers require prior authorization before services being rendered.
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
magnetic resonance imaging (MRI) lumbar spine (72141) to be provided by an OON provider.
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 LTACHs do not provide clinical advantage over a non LTACH acute care
hospitals.
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 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.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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral x-ray images (D0220, D0230) and core buildup
procedures (D2950) provided on December 2, 2020.
You asked the Plan to pay for the dental services. You say that you cannot afford these services and would not
have had them done if you knew they would not be covered. The Plan denied your request. The Plan says the
core buildup procedures are not covered by your dental benefits. The Plan also says that they have already paid
for one intraoral x-ray for you in October 2020, which means that the additional intraoral x-ray images you
received exceed the limitations of the 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 or are requested in a frequency that is not covered under this benefit.
Therefore, we decided that the Plan does not have to pay for intraoral x-ray images (D0220, D0230) and core
buildup procedures (D2950) provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213) provided on January 12, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that both the servicing provider and the facility are in network and do not need prior authorization. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 pay for 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. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99213) provided on January 12, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. The Plan denied your request. The Plan says the inserts requested are not an integral part of the AFO brace nor is it documented the inserts are medically necessary for the proper function of a brace.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 this 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 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. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you have previously used these items and they are a necessity. The Plan denied your request. The Plan says these items are not covered by Medicare because they are not used to take care of medical needs.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and sleeve provided to the enrollee on
March 11, 2021.
You asked the Plan to pay for the orthosis and sleeve. You say that this should be covered by the Plan. The
Plan denied your request. The Plan says that documentation submitted did not include a valid physician order,
Proof of Delivery, or a Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery. The proof of delivery submitted does not include an
itemized statement indicating what was delivered. The record shows that the Plan made several attempts to
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay
for the knee orthosis and sleeve provided to the enrollee on March 11, 2021.
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 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
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but
there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that you need to have certain tests done to
see what is causing your sever allergies. The Plan denied your request. The Plan says there are in-network
providers available for these services.
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 a specialist office visit to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing services.
You asked the Plan to pre-approve the continued skilled nursing services. You say that the enrollee needs an
extension for the skilled nursing facility because they are not ready to be released. The Plan denied your
request. The Plan says the continued admission in a skilled nursing facility does not meet the requirements for
approval.
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 continued skilled nursing services.
Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer
found the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that requires
the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for
coverage of the continued skilled nursing services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence garment, any type (A4520).
You asked the Plan to pre-approve incontinence supplies. You say that you are appealing for authorization for plastic pants because you feel they are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence garment, any type (A4520).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy (G0151 x 10).
You asked the Plan to pre-approve the home health services. You say that the enrollee requires physical
therapy at home. You say that the enrollee does not have transportation to receive these services outside of their
home. The Plan denied your request. The Plan says the enrollee is not homebound. The Plan says that the
enrollee has a transportation benefit that can be used for transportation to and from outpatient physical therapy.
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 services. Our reviewer
says that the home health services are not medically necessary. Our physician reviewer found the provided
documentation does not support that the enrollee is homebound. The reviewer found that the enrollee has been
medically stable without any recent exacerbation of chronic medical problems or hospitalizations. Therefore,
the reviewer found that the home health services are not medically necessary as the member can receive
services on an outpatient 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 home health services have not been met. Specifically, the record does not
show that you are homebound. Therefore, we decided that the Plan does not have to pre-approve home health
physical therapy (G0151 x 10).