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

We decided that the Plan does not have to pre-approve IRFadmission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee meets criteria for IRF. The Plan denied your request. The Plan says admission to an IRF is 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 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 is currently residing in the home. She had an acute hospital evaluation for hypoglycemia and anemia on June 25, 2020 and was discharged back to her home with physical therapy and occupational therapy services. She had previously spent June 3, 2020 to June 25, 2020 in skilled nursing after an inpatient admission for acute CVA. There is no documentation that she requires inpatient supervision by a rehabilitation physician. The submitted records document a need for physical and occupational therapy services but do not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe mattress, cover, adjustable base, and sales tax.You asked the Plan to reimburse you forthe mattress, cover, adjustable base, and sales tax. You say that your doctor recommended the bed due to your medical conditions.The Plan denied your request. The Plan says the adjustable bed isnot primarily used to serve a medical purpose.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Medicare only covers hospital bed. Therefore, we decided that the Plan does not have to reimburse you forthe mattress, cover, adjustable base, and sales taxprovided on February 17, 2020.
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 are appealing the denial for IRF admission and
the records should support the necessity of the service. The Plan denied your request. The Plan says your
request for IRF admission does not meet the requirements for approval. Care can be provided at a less intensive
setting of care like a skilled nursing facility or home with home health care.
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 enrollee's
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not
support that he requires an 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 forCPT codes 95913 and 95886 provided on August 30, 2019.You asked the Plan to pay forCPT codes 95913 and 95886. You say that the medical records support the billing of CPT code 95913.The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 95913.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 95913 is Nerve conduction studies; 13 or more studies. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for CPT codes 95913 and 95886. Our reviewer says that the medical records do not support the billing of CPT code 95913. Our physician reviewer found the medical records submitted do not include documentation to support a Nerve conduction studies; 13 or more studies being performed on August 30, 2019, therefore this service cannot be verified. The National Correct Coding Initiative Policy Manual for Medicare Services describes CPT 95913 as follows: "Three types of nerve conduction studies are represented by these codes: sensory conduction, motor conduction (with or without an F wave test), or an H-reflex test. Electrodes are placed directly over the nerve, in sensory conduction testing, or over the motor point of a specific muscle in motor conduction testing. Electrical stimulation is applied. The latency, amplitude, and conduction velocity of the stimulation are measured. Adjustmentsto any of the testing elements (stimulus site, recording site, ground site, filtered settings) are made to minimize unintended stimulation of adjacent nerves. A report is generated on site that interprets the numerous test results at each site tested. Each type of study is reported only once regardless of the number of times performed on the same nerve in different areas. urthermore, Medicare rules say that CPT code 95886 is a Type 1 add-on code and must be reported with a proper Primary Code. In this case, as CPT code 95886 was billed with a Primary code that is not payable, the add-on code cannot be paid separately.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof CPT codes 95913 and 95886 have not been met.Therefore, we decided that the Plan does not have to pay forCPT codes 95913 and 95886 provided on August 30, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee does not have a history of osteoporotic fracture, or has had previous treatment, contraindication, or intolerance to Zoledronic acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our physician reviewer found that the enrollee has a past medical history of atrial fibrillation, heart failure and gastroesophageal reflux disease. There is no reported history of osteoporotic fracture. The Plan requires a trial of Zoledronic acid, or have a history of osteoporotic fracture before they will approve the requested drug. The enrollee has not tried and failed the required drug, and there is no reported history of osteoporotic fracture. There is no indication that the plan's required drug would likely be less effective, and/or likely have adverse effects for the patient.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe electrical stimulation services and injection services provided on November 20, 2019.You asked the Plan to pay forthe electrical stimulation services and injection services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe electrical stimulation services and injection services provided on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 1mg Warfarin Sodium Tablets. You asked the Plan to pre-approve the Warfarin. You say that you would like reconsideration because this drug is medically necessary. 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 1mg Warfarin Sodium Tablets. Benefits for the Warfarin 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 waive the coinsurance for the walking boot and crutch rendered to you on October 19, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you had a fall while traveling out of town and the out-of-network cost is a financial hardship. The Plan denied your request. The Plan says the coinsurance was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 30% coinsurance for out-of-network durable medical equipment and related supplies.
Review of the file shows that you received a walking boot and crutch from an out-of-network provider on October 19, 2019. You have been asked to pay a 30% coinsurance for these services, for a total of $99.52. These services fall within the out-of-network durable medical equipment and related supplies 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 walking boot and crutch rendered to you on October 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 6/11/20 with diarrhea, vomiting, syncope, and dyspnea. He was diagnosed with sepsis, GI bleed, pneumonia, and acute kidney insufficiency, and treated with mechanical ventilation, tube feeds, dialysis, IV Zosyn, IV antibiotics, and monitoring. Current documentation shows that although he successfully was extubated, the enrollee requires regular hemodialysis, physical therapy, PEG tube placement, and monitoring of his atrial fibrillation. Although it appears that the enrollee appears to still require at least short-term use of acute care services for PEG tube placement and additional monitoring, the enrollee does not appear to require services at the LTACH that are not already available at the current acute care facility. There are no services which are available at the proposed LTACH that the enrollee requires that are not already available and covered by the current acute care facility. Therefore, as continued care at the current facility until able to discharge to a lower level of care would be most appropriate according to the notes provided, this request for LTACH services will be considered not 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided December 1, 2019 to December 5, 2019.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 copayment per day, for days 1-6 and a $0 copayment per day, for days 7-90 for each inpatient hospital admission. You have been asked to pay a $1,160 copayment ($290 x 4 days) for inpatient hospital care. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided December 1, 2019 to December 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve back surgery at lumbar levels 3-5.
You asked the Plan to pre-approve the back surgery. You say that you would like reconsideration because this
surgery is medically necessary. The Plan denied your request. The Plan says there is a lack of physical
examination and documentation that is suggestive of nerve root or spinal cord compression.
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 back surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation of a physical examination which is needed to show
neurologic involvement.
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 back surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve back surgery at lumbar levels 3-5.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reblozyl.You asked the Plan to pre-approve Reblozyl. The Plan denied your request. The Plan says the drug requires that the enrollee is unable to achieve treatment goals with an adequate trial of an erythropoiesis stimulating agent (Retacrit).Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Reblozyl. Our physician reviewer found that the enrollee has Myelodys plastic syndrome with isolated del(5q) chromosomal abnormality. The Plan requires a trial of an erythropoiesis stimulating agent (e.g. Retacrit) before they will approve the requested drug. The documentation does not indicate that the enrollee has tried and failed the required drugs. The documentation does not support that an erythropoiesis stimulating agent would likely be less effective, or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to reduce the cost for the ER visit provided on February 1, 2020.
You asked the Plan to reduce the cost for the ER visit. You say that you should only pay a $120 copayment. The Plan denied your request. The Plan says that the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan does not say in clear and accurate terms whether the deductible should apply to emergency care. The Plan says you must pay $168.20 toward the deductible for the ER visit. Based on the Plan contract, however, you cannot be asked to pay more than a $120 copayment for the ER visit. The Plan contract does not clearly disclose whether the deductible should apply to emergency care. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the $168.20 applied toward the deductible and apply the $120 copayment for the ER visit provided on February 1, 2020.
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 would like reconsideration because the IRF
admission is medically necessary. The Plan denied your request. The Plan says the member can safely receive
the necessary services in a lower level of care.
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 member's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member's
medical status does not currently require intensive physician and nursing oversight 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from March 23, 2018 to March 26, 2018.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the service was not medically necessary because the enrollee was not receiving physical, occupational or speech therapy.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from March 23, 2018 to March 26, 2018.