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 IRF services are medically necessary. The Plan
denied your request. The Plan says admission to an IRF does not meet criteria, is not medically necessary, and
a lower level of care may be appropriate.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 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. Medical
conditions are stable. The enrollee does require physical and occupational therapy but there is no documented
need for an intensive rehabilitation program. Medically necessary services can be provided in a different level
of care. 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: 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 SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found although the enrollee requires skilled nursing care and skilled physical therapy care on a daily basis, the enrollee is not stable for transfer. Therefore, continued care in the acute inpatient rehabilitation facility is appropriate (and endorsed by the health plan) until the patient is stable to transfer to a lower level of care such as an assisted living facility or a long-term care facility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an inpatient admission provided from August 21, 2020, through September 15, 2020.
You asked the Plan to pay for the inpatient admission. You say that the inpatient admission was approved by the Plan and you provided the medical records for this admission. The Plan denied your request. The Plan says that medical records were not provided from a prior hospital stay from August 4, 2020, through
August 11, 2020.
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 has not provided documentation that the Plan paid an inpatient claim for the hospital stay provided from August 7, 2020, through August 11, 2020 to substantiate denial for a readmission. Additionally, the file shows that the Plan approved the inpatient admission provided from
August 21, 2020, through September 15, 2020. Therefore, we decided that the Plan has to pay for an inpatient admission provided from August 21, 2020, through September 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal aortography provided on October 8, 2020 billed with code 75625.

You asked the Plan to pay for the aortography. You say that it is felt this claim was billed correctly. The Plan denied your request. The Plan says other codes were approved; however, 75625 remains unsupported by records.

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 75625 is aortography, abdominal, by serialography, radiological supervision and interpretation.

We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the aortography. Our reviewer says that the documentation does not support the billed code. Our coding reviewer found the procedure report does not document an abdominal aortography procedure. No description of the procedure was documented, and as such, CPT 75625 cannot be confirmed. Procedure report documents a "left leg angiogram with possible intervention". 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the aortography have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal aortography provided on October 8, 2020 billed with code 75625.
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 you do not meet criteria for IRF services and you can safely receive the services needed in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 complexity of your nursing, medical and rehabilitation needs do not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ophthalmological services (CPT code 92014) and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (CPT code 92133) provided on January 27, 2021, by an out-of-network provider.
You asked the Plan to waive the deductible for the services. You say that you called the provider and they were in-network. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received ophthalmological services and scanning computerized ophthalmic diagnostic imaging on January 27, 2021. At the time of services rendered you had not met your $198 deductible; therefore, you have been asked to pay $157.13 for the services to apply to your deductible. This claim was due to your deductible not being met, not because the provider was out-of-network. 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 deductible for the ophthalmological services (CPT code 92014) and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (CPT code 92133) provided on January 27, 2021, by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care provided on February 23, 2021.
You asked the Plan to waive the copayment for the emergency care. You say that you told the staff numerous times about what you needed done but the staff was being insistent on admitting you and they ended up doing all of the same tests as the heart group and never did the intravenous (IV) infusion. You state you were billed for the tests you already had and it wasn't much but you didn't request those services (only the IV) and was forced to do them. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
Review of the file show that you received emergency care on February 23, 2021. You were asked to pay a $65 copayment for the emergency care. Your 2021 EOC states that enrollees must pay a $65 copayment for emergency 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 emergency care provided on February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced foot and ankle feature.

You asked the Plan to pre-approve an advanced foot and ankle feature. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that an axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or 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 an advanced foot and ankle feature. Our reviewer says that the items are not medically necessary. Our physician reviewer found the request exceeds your medical needs as there is no evidence on the treating medical physician progress notes that you are a K3 ambulator given the documentation of your multiple medical comorbidities, shortness of breath with activity, lumbar pain, no evidence of exercise and documentation of being disabled. Furthermore, there is no indication on the medical progress notes that you are unable to use your current foot with the approved socket.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an advanced foot and ankle feature have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced foot and ankle feature.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cystourethroscopy, with insertion of permanent adjustable transprostatic implant.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says sufficient information was not received in the medical records.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare Rules. Based on this information, we decided that Medicare rules for the services at issue have not been met. Specifically, the case file did not contain medical records for the requested services. Without the medical records, the requested services cannot be verified as medically necessary. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve cystourethroscopy, with insertion of permanent adjustable transprostatic implant.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sinusotomy and excision of nasal polyps.

You asked the Plan to pre-approve surgical services. You say that other treatments have not helped your condition and you do not know what else to do. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because there is no evidence of sinus pathology and no evidence of polyps.

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 surgical services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the reasoning behind recommending these procedures is not clear. Your Computed Tomography (CT) scan results do not show any evidence of either acute or chronic sinusitis. There is no documentation supporting that you have sinonasal polyps. The Academy of Otolaryngology guidelines clearly do not recommend performing a sinus procedure when there is no evidence of disease on a CT scan.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgical services have not been met. Therefore, we decided that the Plan does not have to pre-approve sinusotomy and excision of nasal polyps.
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 you need LTACH services. The Plan denied your request. The Plan says the services needed can be provided in another type of 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 pre-approve 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 appears to not be a candidate for LTACH and does not have sufficient current acute care needs and does not require complex wound care management or daily physician visits. The patient does not require services at the LTACH that would not be available at her home via home health services or an appropriate skilled nursing facility. There are no services at the LTACH that the patient requires that would not already be available and covered at a lower level of care. Therefore, this request for LTACH services is not sufficiently supported and will be considered not medically necessary. Transfer to a more appropriate facility or utilization of home health services would be more appropriate in this case, according to the provided records.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there are no daily skilled nursing or therapy needs.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our physician reviewer found that you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are consistently ambulating more than 100 feet and tending to ADLs with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial.

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 pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Vectibix (J9303).
You asked the Plan to pre-approve Vectibix. You say that this request is medically necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Vectibix. Our reviewer says that the requested drug is medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the enrollee is a 65-year-old who has been diagnosed with metastatic colon cancer. In this case, Vectibix is FDA approved for the enrollee's condition. This drug would be considered medically reasonable and necessary to treat the enrollee's cancer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vectibix have been met. Therefore, we decided that the Plan has to pre-approve Vectibix (J9303).
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 Plan has 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met at home, or in an assisted living facility with supervision and home health care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 enrollee has stabilized medically, and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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) 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 you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says member does not require an intensive therapy program with multiple visits from a doctor per week.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.

There is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different 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.