Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on October 22, 2019.You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan saysthatthe Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for ophthalmological services providedon October 22, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the SNF care provided from October 2, 2019 to October 15, 2019.
You asked the Plan to pay for SNF care. You say that the enrollee needed skilled nursing care in order for her to recover properly. The Plan denied your request. The Plan says that the enrollee does not meet the CMS medical necessity criteria.
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 SNF care. Our reviewer says that the enrollee met the Medicare criteria for SNF care. Our physician reviewer found the enrollee did have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pay for the SNF care provided from October 2, 2019 to October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee on November 15, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that there was a medical necessity pre-established with the enrollee and the facility.The Plan denied your request. The Plan says there is no valid referral for this 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee on November 15, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee is not appropriate for a skilled nursing facility.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 rulesto 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 admitted to the hospital with indigestion and left upper extremity pain. He underwent an aortic valve replacement and three-vessel coronary artery bypass grafting. He is now medically stable with no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He is ambulating household distances and does not require an intensive rehabilitation therapy 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 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 3, 2019.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary, resthome visit on December 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fortheservices rendered to the enrollee on February 14, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 84432 is not supported.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 84432 is assay of thyroglobulin.We find that CPT code 84432 is not supported in the medical record. Specifically, there is no documentation of a lab order for assay of thyroglobulin. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, wedecided that the Plan does not have to pay forthe services rendered to the enrollee on February 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on April 24, 2019 to April 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were provided in skilled nursing facility. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on April 24, 2019 to April 26, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on November 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were unaware that you were not in network. The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on November 6, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on October 11, 2019 by an out of network (OON) provider. You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says services from non-participating providers are not covered under the plan unless they are authorized before the services are provided. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on October 11, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of tumor treatment field therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says the therapy is only being used 33% of the time.
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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of adherence to therapy - defined as using tumor treatment field therapy for an average of 18 hours per day. The therapy has not shown a documented benefit. 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of tumor treatment field therapy for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient admission requested on March 15, 2020.
You asked the Plan to pay for the inpatient admission. You say that the enrollee has required continued hospital care due to her condition and is not yet stable for discharge. She has received over two midnights of care. The Plan denied your request. The Plan says the enrollee does not meet criteria for inpatient admission.
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 pay for the inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the enrollee is a 77 year old female with a history of atherosclerotic cardiovascular disease, obesity, diabetes and hypertension who presented to the hospital with severe chest pain of 4 to 5 days duration on 3/13/2020. She was found to have no acute cardiac issues but continued with pain for the next two days at which time inpatient admission was requested. Evaluation in the hospital found no evidence of cardiac ischemia by serial troponins and negative EKG findings. There was artifact on the EKG. A chest x-ray and chest CT scan showed cardiomegaly with no other acute disease - no pulmonary embolus. She had no deep vein thrombosis on lower extremity ultrasound. Her laboratory tests showed no acute abnormalities. She was treated with beta-blockers, isosorbide, aspirin, furosemide, a statin, Protonix as well as Tylenol, tramadol, oxygen and nitroglycerin. She was seen by cardiology who felt there was no evidence of cardiac ischemia and out-patient follow-up was appropriate. Based on the records provided at the time of the requested for inpatient admission, care at the observation level appeared to be appropriate as the patient did not meet criteria for inpatient care due to the lack of imaging, EKG or laboratory abnormalities. 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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient admission requested on March 15, 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 the enrollee needs acute care for her conditions and
would benefit from three hours of daily therapy in an intensive program. The Plan denied your request. The
Plan says IRF criteria are not met in this case.
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 a female who was recently treated for the flu on 3/2 and was admitted
on 3/9 with worsening cough and poor oral intake. She was found to have acute kidney injury and a COPD
exacerbation. Since admission her creatinine has worsened, lethargy has worsened, and she had a low-grade
fever, tachycardia and SpO2 90 % on 3/13. The complexity of the patient's nursing, medical and rehabilitation
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in
an IRF. The documentation reveals that the patient requires continued medical management to ensure stability
prior to any rehabilitation transfer. The patient continues to have elevated creatinine, rising WBC count and
dizziness with standing in therapy. The patient may benefit and participate in additional therapy of PT and OT
but the patient does not appear to be able to tolerate this or 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: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pre-approve 28 further sessions of outpatient psychotherapy for the enrollee.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that 28 further outpatient psychotherapy visits, for a total of 32 visits, are not medically necessary; however, the Plan has not provided any medical records. Without medical records, a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-approve 28 further sessions of outpatient psychotherapy 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.
You asked the Plan to pre-approve IRF care. You say that it is felt that IRF services are required for this enrollee. The Plan denied your request. The Plan says the enrollee is currently medically stable and has no need for an intensive therapy program.
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 a male who sustain cervical and lumbar spine fractures in a motor vehicle accident. He was treated non-surgically with a brace immobilization. Based on review of the available records, the patient does not meet criteria for IRF admission. The patient was medically stable with no evidence of need for supervision by PMR Physician or needs acute rehab nursing care. She may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on her current functional status and medical stability. 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 18, 2019 through August 21, 2019. You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary. 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 pay for 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 review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (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 pay for the acute inpatient hospital care provided from August 18, 2019 through August 21, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the lumbar spine (72131).
You asked the Plan to pre-approve a CT scan of the lumbar spine. You say that the service is necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 a CT scan of the lumbar spine. Our reviewer says that the service is medically necessary. Our physician reviewer found the first CT of the lumbar spine was done on January 22, 2020 and was interpreted with the record in the submitted records. The denial states an approval was issued for CT of the lumbar spine on February 10, 2020. It is assumed this approval was for the second exam as requested by the designated surgeon with specific technique designed for operative planning. As the second exam is needed by the surgeon for planning it would meet the criteria for medical necessity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the lumbar spine have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the lumbar spine (72131).