Persius/hicric huggingface dataset:
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-approvethe LTACH services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. 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 services are not medically necessary. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in the current acute care setting. 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 health plan has approved ongoing care in the current acute care setting. 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-approvelong term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forself-administered drugs provided on October 7 to October 8, 2019. You asked the Plan to pay forthe self-administered drugs. You say that the medications should be covered.The Plan denied your request. The Plan says self-administered drugs provided in an outpatient setting are not eligible for coverage under the Part B medical benefit.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 forself-administered drugs provided on October 7 to October 8, 2019. Benefits for the 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: 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 requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the member was admitted on 02/03/2020 with altered mental status. A CT scan showed findings of a subacute left temporal parietal/occipital lobe infarct. She required treatment for hypertensive emergency and encephalopathy. She developed leukocytosis and was treated with empiric antibiotics which were discontinued on 02/05/2020. Her relevant past medical history also includes mixed hyperlipidemia, Type II diabetes, iron deficiency, and hypothyroidism. As of 02/09/2020 she was alert and oriented. She was concerned about her overall situation. She was evaluated for physical therapy on 02/10/2020. The member lives alone and had previously used a rolling walker inside and bilateral canes outside. She lives in a single level residence with 3 steps to the entrance. She had been otherwise independent. She had pain rated at 4/10. She required minimal assistance when ambulating 40 feet with a rolling walker and when transitioning from seated to standing. She had improving mobility and endurance. She now required assistance of only 1 person rather than 2. She remained at risk for falls and was limited by fatigue. The member is status-post acute care admission with findings of a subacute stroke as described above. The member's medical conditions appear stable. There are no wound care needs. She does not require medical oversight of her condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. She is ambulating near household distances and does not require an intensive rehabilitation therapy program. The member is limited by fatigue. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve prednisone 5mg tablets.You asked the Planto pre-approvethe prednisone tablets. You say that the enrollee needs this medication.The Plandenied your request. The Plansaysthis oral 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 Plandoes not haveto pre-approveprednisone 5mg tablets.Benefits forthe prednisone tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay fora trastuzumab injection (J9355-JW) provided on July 1, 2019 by "the doctor".You asked the Plan to pay forthe trastuzumab injection. You say that the claim was billed correctly and payment should be rendered.The Plan denied your request. The Plan says the modifier was not billed per Medicare guidelines. Therefore, coverage criteria has 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 J9355 is a trastuzumab injection.We asked our Maximus coding 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 trastuzumab injection. Our reviewer says that the service is not supported in the billing. Our coding reviewer found multi-use vials are not subject to payment for discarded amounts of drug or biological. This is a case of inappropriate use of the JW modifier. Therefore, J9355 JW does not meet criteria for billing or reimbursement consideration.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 trastuzumab injection have not been met.Therefore, we decided that the Plan does nothave to pay fora trastuzumab injection (J9355-JW) provided on July 1, 2019 by "the doctor".
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you needed emergency services for an allergic reaction and after some time you were stable. You say that you received needed services during a crisis and you believe the charges should be covered.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 2, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe bone replacement graft (D7953) and the biologic materials to aid in soft and osseous tissue regeneration (D4265) provided on September 30, 2019.You asked the Plan to reimburse you forthe dental services. You say that the dentist would not remove your tooth if the services you received were not approved. You also say that you had to pay out of pocket for the services.The Plan denied your request. The Plan says the dental services you received are not covered services.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 bone graft regeneration and biologic materials to aid in tissue regeneration are not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you forthe bone replacement graft (D7953) and the biologic materials to aid in soft and osseous tissue regeneration (D4265) provided on September 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued treatment atan out-of-network provider. You asked the Plan to pre-approvecontinued treatment with an out-of-network provider. You say that the requested continued treatment is medically necessary. The Plan denied your request. The Plan says the enrollee can receive these services at an in network provider. Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.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 continued treatment with an out-of-network provider. Our reviewer says that the requested continued treatment at an out of network provider is not medically necessary. Our physician reviewer found the enrollee has been receiving neurological physical therapy for encephalitis and aquatic physical therapy at an out-of-network provider. The Plan states the enrollee can receive these services in-network at a physical therapy facility. An appeal letter for the enrollee from the enrollee's physical therapist states that she has balance/walking difficulty in the setting of brain injury, neck pain and low back pain, and weakness in both upper extremities. She is noted to be a good candidate for improvement with neurological and aquatic physical therapy. A 1/14/20 medical report notes she has ankylosing spondylitis, osteoarthritis of the knees, movement disorder, scaphoid fracture, and C. difficile. An appeal letter states that she suffers from acute illnesses and her immunity is compromised and she cannot use other community pools. In this case, the documentation shows that the Plan is offering adequate care to meet the enrollee's medical needs through referral to an in-network provider. There is not anything unique about the enrollee's condition that would make it medically necessary for her to see the requested out-of-network provider.The documentation does not reveal what autoimmune disorder would prevent the enrollee from using the in network provider and a clear rationale on why the out of network pool would be beneficial for the enrollee's autoimmune condition or for the enrollee'smedical conditions. The Plan has shown that they have in-network providers who meet the standards of care required for treatment of the enrollee's condition. It is not medically necessary for the enrollee to receive the requested neurological and aquatic physical therapy services with the out-of-network provider. The enrollee can safely receive these services with the in-network provider.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued treatment with an out-of-network provider have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued treatment at an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee does not require this on an intensive rehabilitation facility therapy program level 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 occipital nerve blocks (64490, 64491, and 64492).
You asked the Plan to pre-approve occipital nerve blocks (64490, 64491, and 64492). You say that the requested occipital nerve blocks are medically necessary. The Plan denied your request. The Plan says the requested occipital nerve blocks do not meet criteria.
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 occipital nerve blocks (64490, 64491, and 64492). Our reviewer says that the requested occipital nerve blocks are not medically necessary. Our physician reviewer found the enrollee has chronic neck pain without radiation. She has multi-level degenerative changes in her cervical spine and status post fusion. She also has chronic daily headache and the request is for occipital nerve blocks. The efficacy of occipital nerve blocks for daily headache is not evidence based. The enrollee has also failed the radiofrequency ablation (RFA), so repeat injections at that level are not indicated. The requested procedures are not medically reasonable or 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 occipital nerve blocks (64490, 64491, and 64492) have not been met. Therefore, we decided that the Plan does not have to pre-approve occipital nerve blocks (64490, 64491, and 64492).
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-approvethe LTACH services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. 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 services are not medically necessary. Our physician reviewer found the submitted records show that you do not require any services at the LTACH that are not available at the acute care hospital where you are currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services at the LTACH that you need that are not available at the setting being provided by the plan. LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition.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-approvelong 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 1/28/2020 for coronary artery bypass graft, excision of left atrial appendage and extensive Maze procedure. Post-operative course was complicated by acute respiratory failure requiring BiPAP. Presently the enrollee is deconditioned with decreased endurance and requiring assistance with activities of daily living, transfers and ambulation. Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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 pre-approve knee arthroscopy with meniscal shaving for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation that the enrollee has had an adequate trial and failure of conservative therapy for knee pain and stiffness. A six week trial of physical therapy is needed prior to surgery. The submitted documentation does not support that the requested procedure is reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve knee arthroscopy with meniscal shaving for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services forthe enrollee. You asked the Plan to pre-approveIRF care. You say that you disagree with the denial.The Plan denied your request. The Plan saysthe services are not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was brought to the emergency room (ER) on January 1, 2020 with complaints of right thigh pain and was discharged to a skilled nursing facility on January 10, 2020. He needs maximum assist for feeding and is dependent with dressing, bathing, and transfers. He is medically stable with no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He is limited by comorbid conditions and dementia and is not expected to fully participate in or benefit from an intensive therapy program in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.