Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee would do better in the IRF setting. The Plan denied your request. The Plan says the 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 requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted for surgical treatment of left tibial and fibular fractures after a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay forK3 lower limb prosthesis.You asked the Plan to pay forthe K3 lower limb prosthesis. You say that the enrollee requires the K3 lower limb prosthesis. The enrollee has a strong desire to return to their previous state of doing 'beyond simple walking'.The Plan denied your request. The Plan says that no objective clinical documentation is provided in the office visit note or therapy notes that support member as K3 ambulator.The Plan must follow Medicare rules. Medicare rules say that a Level 3 ambulator has the ability or potential for ambulation with variable cadence, typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. The documentation from both the in personmedical examination and the order indicate the enrollee has the desire and ability to function at the K3 level. They specify that it is beyond the low level environmental barriers that the K2 indicates.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the K3 lower limb prosthesis have been met.Therefore, we decided that the Plan has to pay forK3 lower limb prosthesis.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs HF System.
You asked the Plan to pre-approve these 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. 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 the enrollee has NYHA Class III congestive heart failure with reduced left ventricular ejection fraction (LVEF less than 20 percent) requiring hospital admission. In this circumstance, therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. The CardioMEMs device is considered experimental/investigational in nature and not the standard of care. The services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs HF 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.
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan
denied your request. The Plan says 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 enrollee is not shown to require fifteen hours per week of rehabilitative services
and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5mg Eliquis.
You asked the Plan to pre-approve the Eliquis. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says this drug is not covered for the member's
condition under 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 5mg Eliquis.
Benefits for the Eliquis 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that you will benefit from short-term rehab. The Plan denied your request. The Plan says this is not a covered benefit.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not support that skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse is required to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not have complex wound care or other SN needs that requires a SNF stay. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. Skilled services are not needed on a daily basis or as practical matter in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation.You asked the Plan to pre-approveadditional routine transportation. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee has exhausted the transportation benefitfor the 2021 benefit year.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 24 one-way transportation 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-approveadditional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.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-approvethe 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 appears to be stable and gradually improving and requires only additional short-term acute care services that would be safe to complete at the current setting. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that are not already available and covered at the current setting. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be completed when treatment has completed and they are appropriate for a lower level of care setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approvethe acute inpatient hospital care.You asked the Plan to pre-approveacute inpatient hospital care. You say that you would like reconsideration because the inpatient care is medically necessary.The Plan denied your request. The Plan says that this care canbe provided at an observation level.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatientadmission the admitting physician reasonably expected that the member's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pre-approvethe acute inpatient hospital care.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the open treatment of a fracture provided
on October 1, 2020.
You asked the Plan to waive the coinsurance for the open treatment of a fracture. You say that you disagree
with the charges because you had to return to have your shoulder reset. 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 20%
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You received the open treatment of a fracture on October 1, 202. The total allowed amount is $5,892.58 and
20% of that is $1,178.52.
You have been asked to pay the total coinsurance amount of $1,178.52 for the open treatment of a fracture. The
open treatment of a fracture falls within the outpatient surgery, including services provided at hospital
outpatient facilities and ambulatory surgical centers 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
coinsurance for the open treatment of a fracture provided on October 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF) care.You asked the Plan to pre-approvethe continuation of SNF care. You say that the requested continuation of SNF care is medically necessary.The Plan denied your request. The Plan says the enrollee disenrolled from the Plan on December 31, 2020.The Plan must follow Medicare rules. Medicare rules say that with respect to enrollees receiving care in a SNF upon the termination of the MA contract, terminating MA organizations are financially liable for such care through December 31 of the final contract year. After that date, Medicare beneficiaries continuing a SNF stay may receive coverage through either fee-for-service Medicare or enrollment in another MA plan.We looked at the file and Medicare rules. The file shows that you disenrolled from this Plan on December31, 2020. The Plan paid for the SNF services received on December 31, 2020; however, starting January 1, 2021 SNF coverage would be under either fee-for-service Medicare or enrollment in another MA plan. Based on this information, we decided that Medicarerules for coverage of the continuation of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF) care
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for any of the dental services provided on January 7, 2020.
You asked the Plan to pay for these dental services. You say that you were under the impression these services would be covered. The Plan denied your request. The Plan says neither the Plan nor Medicare will pay for services from providers who have opted out of the program. Maximus agreed with the health plan. The Plan requested a reopen and requested a corrected letter be issued to include codes D7210 and D0140.
The Plan is correct in this case. In regard to providers, the Plan must follow Medicare rules. Medicare does not pay for care from providers who are not eligible to accept Medicare Payment. Medicare also does not pay for dental services. Therefore, in regard to dental services, the Plans contract rules apply for coverage. These services were rendered by a provider who is not eligible to take the Plans payment structure based on general Medicare guidelines for providers. Therefore, we decided that the Plan does not have to pay for any of the dental services provided on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for COVID-19 pneumonia. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.
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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvea spinal surgery revision procedure (20930, 20936, 61783).You asked the Plan to pre-approvethe surgical revision. You say that the service is medically necessary.The Plan denied your request. The Plan says that the requested procedure is not the standard of care and is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 surgical revision. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found while there are additional risks associated with use ofBone Morphogenic Protein(BMP)during spinal fusion revision, in this case there was already a dramatic structural failure as indicated by the failure of hardware. The spine is currently at risk of instability, recurrent non-union, and neurologic sequela. In this case, the revision procedure, particularly with the use of BMP, is appropriate.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 surgical revision have been met.Therefore, we decided that the Plan has to pre-approveaspinal surgery revision procedure (20930, 20936, 61783).If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Planhas to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvegenetic testing for Exome sequence analysis for the enrollee.You asked the Planto pre-approvethe testing. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no clinical evidence to support the medical necessity of this testing.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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have pernicious anemia, immunodeficiency and adrenal insufficiency. Testing specifically related to these conditions, for which associated therapies are known, is medically necessary and reasonable. Panel testing, inclusive of testing that is not related to these conditions or for which there are no associated therapies, is not medically necessary or reasonable. The documentation does not support that the requested whole exome sequence testing is medically necessary or reasonable.
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 testing have not been met.Therefore, we decided that the Plandoes not haveto pre-approvegenetic testing for Exome sequence analysis for the enrollee.