Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says IRF admission 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 that the enrollee has multiple complex medical conditions. There would be an expected need to modify the enrollee's treatment in order to maximize his capacity to benefit from rehabilitation including through optimization of his medications including for his Parkinson's Disease. Specialty nursing care is indicated for managing his incontinence and for developing a bowel/bladder program. The complexity of the enrollee's nursing, medical management and rehabilitation needs require an inpatient stay and an interdisciplinary team approach to the delivery of his rehabilitation care. However there are no unaddressed medical issues and no wound care needs. He does not require an acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, there is no reason that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at an SNF 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: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve2 bilateral levels. We decided that the Plan does not have to pre-approve1 bilateral level. You asked the Plan to pre-approve2 bilateral levels. The Plan says that coverage criteria have not been met. We decided that the Planhas to pre-approve2 bilateral levels. The Plan follows Medicare rules. Medicare rules say that for each covered spinal region (cervical/thoracic or lumbar), no more than two joints bilaterally thermal RF sessions will be reimbursed in any calendar year, involving no more than four joints per session.
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 2 bilateral levels. Our physician reviewer found you have chronic axial low back pain. You had 2 diagnostic medial branch blocks covering 3 levels bilaterally. You achieved greater than 80% pain relief each time. 3 levels of radiofrequency neurotomy have been requested. According to the criteria, only 2 levels bilaterally of radiofrequency neurotomy may be performed. Therefore, only 2 bilateral levels are considered medically necessary and 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 2 bilateral levels have been met.Therefore, we decided that the Plan has to pre-approve2 bilateral levels. We also decided that the Plandoes not have to pre-approve1 bilateral level.The Plan follows Medicare rules. Medicare rules say that for each covered spinal region (cervical/thoracic or lumbar), no more than two joints bilaterally thermal RF sessions will be reimbursed in any calendar year, involving no more than four joints per session.Our physician reviewer found According to the criteria, only 2 levels bilaterally of radiofrequency neurotomy may be performed. Therefore, only 2 bilateral levels are considered medically necessary and reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approve1 bilateral level
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approve the services. You say that you want a second opinion from a non-plan provider.The Plan denied your request. The Plan says the services are available in-network.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approve medical services 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 One Touch Ultra Blue test strips for the enrollee.You asked the Plan to pre-approve these services. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers.The items at issue are One Touch Ultra Blue test strips. One Touch Ultra Blue is not a preferred provider with the Plan for diabetic supplies. ACCU-CHEK and Trividia are the preferred providers.Therefore, we decided that the Plan does not have to pre-approve One Touch Ultra Blue test strips for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the onlay -resin-based composite and maxillary partial denture provided on September 19, 2019 and October 5, 2019.You asked the Plan to pay for the onlay -resin-based composite and maxillary partial denture. You say that the Plan's decision is not correct.The Plan denied your request. The Plan says these services are not covered under any circumstances.Medicare generally does not cover dental services. However,the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the onlay -resin-based composite and maxillary partial denture provided on September 19, 2019 and October 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility (SNF) services provided to the enrollee from January 1, 2019 to February 28, 2019.You asked the Plan to pay forSNF services. You say that SNF services were medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for SNF services were not met. 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, the enrollee required varied assistance with daily activity. There were no daily skilled nursing services documented. There were no daily skilled therapy services documented. The enrollee was given oral medication and treated for skin tears. The care provided was not required on a daily basis at a SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pay forskilled nursing facility (SNF) services provided to the enrollee from January 1, 2019 to February 28, 2019.
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. The Plan denied your request. The Plan says IRF admission 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 that the enrollee's medical conditions appear stable. There are no complex wound care needs. There are no unaddressed medical issues. He does not require medical oversight of his condition at an acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. The enrollee is limited by pain after his recent fall and surgery. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. An intensive rehabilitation therapy program would not significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at an SNF 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility (SNF) services provided to the enrollee from May 2, 2019 to May 31, 2019.You asked the Plan to pay forSNF services. You say that SNF services were medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria were not met.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based onthe medical records provided, there were no identifiable daily skilled nursing or daily skilled therapy services required by the enrollee at a SNF level of care for the dates of service in question.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 services have not been met.Therefore, we decided that the Plan does not have to pay forskilled nursing facility (SNF) services provided to the enrollee from May 2, 2019 to May 31, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the thorax (71250).You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says there are no national criteria which suggest serial CT scans of the chest should be performed to monitor pneumonia unless the pneumonia fails to clear.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 wascorrect in denying the request to pre-approve the CT scan. Our reviewer says that the provided notes did not show evidence of incomplete resolution of signs and symptoms or if a secondary cause is suspected. Also, CT would be only indicated when x-ray hadshown unclear results. Our physician reviewer found the repeat CT of the thorax will be considered 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 the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the thorax (71250).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses provided by Contacting Services of America on November14, 2019.You asked the Plan to pay for the knee orthoses (L1833). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says there is no valid physician order or proof of delivery.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay for the knee orthoses provided by Contacting Services of America on November 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that 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 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 readmitted to the hospital on February 24, 2020 for revision of a previous hip surgery for a peri-prosthetic fracture. She was then readmitted to the skilled nursing facility for rehabilitation services. Records show she is making slow progress with therapy. She has no acute issues that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require 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-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from December 1, 2018 to January 31, 2019.
You asked the Plan to pay for this service. You say that SNF services were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. 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 this service. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there were no identifiable daily skilled nursing or daily skilled therapy services required by the enrollee at a SNF level of care for the dates of service in question. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from December 1, 2018 to January 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 10, 2019.You asked the Plan to pay for the dental service. You say that your dentist prescribed to you a maintenance program every 4 months to mitigate the periodontal disease that you have been diagnosed with. You say that you have coverage of up to $2,000 per year for covered dental services. You also say that there is no mention of the frequency of treatment.The Plan denied your request. The Plan says periodontal maintenance is covered 2 times per year. The Plan also says that the frequency limit has been exceeded.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 and periodontal maintenance is a covered service, the frequency limit of 2 times per year has been exceeded. The record shows that the Plan previously paid for this service that you received on  requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from October 22, 2019 through October 23, 2019.You asked the Plan to waive the copayment forthe inpatient stay. You say that you went for a procedure that wasn't completed. You say that you are still in need of the procedure.The Plan denied your request. The Plan says the copayment 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 $250 per day, days 1-7 for each Medicare-covered in-network hospital admission. You have been asked to pay a $250 copayment for the inpatient stay. The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that you were admitted as an inpatient for one day. 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 forthe inpatient stay provided from October 22, 2019 through October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on October 31, 2019.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you were never told that the 2 dental visits allowed by your plan per year had to be at least 6 months apart. The Plan denied your request. The Plan says these services exceed the frequency allowed in your benefit plan.
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, oral exams and prophylaxes (cleanings) are each limited to up to 1 visit every 6 months. The record shows that you received a periodic oral evaluation and prophylaxis on May 21, 2019 and your oral exams and prophylaxis benefits were then exhausted through November 21, 2019. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
You asked the Plan to pay for the LTACH services. You say that this is medically necessary. The Plan denied
your request. The Plan says the enrollee's needs could be met in another setting.
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 pay for the LTACH services. Our reviewer says that
the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician
reviewer found the patient is currently undergoing treatment at an acute care hospital (ACH) for aspiration
pneumonia and sepsis. The enrollee has a tracheotomy and feeding tube at baseline, following a recent stroke.
The enrollee is not on a ventilator. As LTACHs and ACHs are licensed to provide the same level of care, there
is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until
such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of
care for any ongoing long term care needs.
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 pay for long term acute care hospital (LTACH) services.