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

We decided that the Plan does not have to pay for laboratory services provided on October 6, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 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 for laboratory services provided on October 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that inpatient psychiatric care is 
medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria 
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 
psychiatric care. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found 
the enrollee was admitted to the acute inpatient psychiatric hospitalization on July 2, 2021 with Major 
Depressive Disorder, Single Episode Unspecified and Major Neurocognitive Disorder with Behavioral 
Disturbance. The records show it was not expected this enrollee would improve in a reasonable period of time 
beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual 
hallucinations and without aggressive behaviors while not showing any acute threats of safety.  
The enrollee was cooperative and compliant with medication. It did not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual 
hallucinations or abnormal behaviors. It did not appear that active treatment was taking place beyond the date 
in question. There was not an individualized treatment plan. Based upon review the records provided, this 
enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in 
question of August 25, 2021 forward and can be treated in a lesser restrictive 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven (7) home health skilled nursing services CPT 
code G0299 X7), for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the additional approved home skilled nursing visits should be enough to check on the 
enrollee's blood pressure, medications, and help them prepare for discharge. The Plan states if the enrollee's 
doctor determines that more home visits are needed, he or she can submit a request for more visits that includes 
the enrollee's progress and information supporting medical need. 
 
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 services. Our physician reviewer 
found based on the medical records provided there is no documentation that the denied seven skilled nursing 
visits are required to effectively provide treatment, care, and/or services in order to improve the enrollee's 
condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent 
deterioration. Other than asymptomatic high blood pressure the available records do not document any other 
acute/unstable conditions; records do not document why the approved two skilled nursing visits are inadequate 
to address the enrollee's needs at this time; the health plan has stated that additional services will be considered 
if additional supporting records are provided in the future. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve seven (7) home health skilled nursing services CPT code G0299 X7), for the enrollee.
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 admission 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 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 based on 
review of the available records, the enrollee does not meet CMS coverage criteria for an IRF admission. 
The enrollee is medically stable now requiring only bowel and (Ostomy) bladder (suprapubic catheter) care. The enrollee does not require a PM&R physician supervision 3 times per week for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. The documentation does not support the need 
for therapy program consisting of at least 3 hours of therapy per day at least 5 days per week at the current 
level of function. The enrollee will not be able to tolerate the intensity of IRF level of therapies and does not 
need them. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve local anesthesia (D9215 x2). 
 
You asked the Plan to pre-approve local anesthesia. You say that the service is necessary. The Plan denied your 
request. The Plan says the service at issue 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 pre-approve local 
anesthesia (D9215 x2).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pradaxa 75MG Capsules.
You asked the Plan to pre-approve the medication. You say that Pradaxa was prescribed by your doctor more than ten (10) years ago with no side effects. You state since switching to Eliquis, you had two (2) nose bleeds in three (3) days that lasted more than 2 hours. You state you need to be switched back to the Pradaxa blood thinner to avoid a possible stroke. The Plan denied your request. The Plan says this medication falls under Part D coverage, but you have no Part D pharmacy benefit. The Plan states this medication does not fall under Part B. The Plan states they confirmed that you have no commercial pharmacy benefit administered by your health
plan. The Plan states you do have coverage with a different company which provides its own pharmacy 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 pre-approve Pradaxa 75MG Capsules.
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 enrollee would be benefited by foot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ibrance 125mg tablets.

You asked the Plan to pre-approve the Ibrance tablets. You say that this is needed. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B.

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 Ibrance 125mg tablets.

Benefits for the Ibrance tablets 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-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that a shower chair is needed due to poor balance. The Plan denied your request. The Plan says shower chairs are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Hospice
Decision: Unfavorable


We decided that the Plan does not have to pay for urgent care services provided on January 7, 2021. 
 
You asked the Plan to pay for the urgent care services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. The Medicare hospice benefit through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 

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 for urgent care services provided on January 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care.
You asked the Plan to pre-approve inpatient psychiatric care. You say that the requested inpatient psychiatric
care is a medical necessity for you. The Plan denied your request. The Plan says rules for inpatient psychiatric
care have not been met because the requested level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care. Our reviewer
says that the requested level of care is not medically necessary in this case. Our physician reviewer found that,
based upon review of the records provided, it is not expected that you would improve in a reasonable period of
time as you are not showing any dangerousness to self or others, auditory or visual hallucinations and without
aggressive behaviors while not showing any acute threats of safety. You are cooperative and compliant with
medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the
acute inpatient level of care rather than a lower level of care. It does not appear that active treatment is taking
place.
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 psychiatric care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continued inpatient psychiatric care
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation mileage. 
 
You asked the Plan to provide additional routine transportation mileage. You say that the enrollee needs 
transportation for ongoing treatment. The Plan denied your request. The Plan says trips cannot exceed 50 miles 
one way driving distance. 
 
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 routine transportation up to 24 one-way trips per calendar year. Each one-way trip must 
not exceed 50 miles of driving distance.  

We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request would exceed the Plan's rules for mileage coverage. Therefore, we decided that the Plan does 
not have to provide additional routine transportation mileage.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the closed treatment of proximal humeral fracture (23600) provided on November 2, 2020.
You asked the Plan to pay for the closed treatment of proximal humeral fracture. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the service billed.
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 23600 is closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation. We asked our coder 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 closed treatment of proximal humeral fracture. Our reviewer says that CPT code 23600 does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report does not document closed treatment of proximal humeral fracture without manipulation. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the closed treatment of proximal humeral fracture have not been met. Therefore, we decided that the Plan does not have to pay for the closed treatment of proximal humeral fracture (23600) provided on November 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation mileage. 
 
You asked the Plan to provide coverage for additional routine transportation mileage. You say that there are no 
in-network rheumatologists available that are within 50 miles of your home. The Plan denied your request. The 
Plan says the Plan does not cover additional routine transportation or mileage beyond the covered benefit 
allowance. 
 
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.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for coverage of routine transportation have not been met. Specifically, the Plan benefit 
covers up to 50 miles of driving distance. Therefore, we decided that the Plan does not have to provide 
coverage for additional routine transportation mileage.
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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have 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 that you are a 66-year-old male who was admitted to the current acute care hospital with pneumonia and hypoxemia requiring intubation and sedation. Recent notes show worsening respiratory status and unresponsiveness. You appear to be worsening. Additional short-term acute care services are required which can safely be received at the current acute care facility to complete treatment. You do not require services at the LTACH that are not already available at the current facility. In addition, there are no services at the LTACH that you require that are not already available and covered at the current facility.
Therefore, this request for LTACH services will be considered not medically necessary at this time as transfer would not provide a clinical advantage. Transfer may be considered when your long-term care needs are more clear and when treatment has completed. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable loop recorder (procedure codes 93298 x 1 unit, 93291 x 1 unit, 93285 x 1 unit, and 33285 x 1 unit).
You asked the Plan to pre-approve an implantable loop recorder. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 an implantable loop recorder. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has previously undergone an ablation procedure for atrial fibrillation. Since then, the enrollee has been in sinus rhythm when an electrocardiogram (EKGs) have been performed. The benefit of an implantable loop recorder in patients who have been treated with an ablation procedure has not been clearly demonstrated in the medical literature.
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 implantable loop recorder have not been met. Specifically, there is not enough research on this device for the enrollee's specific needs. This means the service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve an implantable loop recorder (procedure codes 93298 x 1 unit, 93291 x 1 unit, 93285 x 1 unit, and 33285 x 1 unit).