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

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with respiratory failure and status epilepticus. The enrollee is currently intubated and has episodes of desaturation and tachycardia. The enrollee is not clinically stable. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.
You asked the Plan to pre-approve the IRF care. The Plan denied your request. The Plan says you do not meet the guidelines for IRF services as the clinical information indicates that your needs may be safely met in a long-term care setting with part-time skilled services.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. Our physician reviewer also found that 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 the acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CT, thorax, diagnostic; with contrast material(s) (CPT code 71260), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your request. The Plan says the Medicare rules have 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 the CT scan. Our physician reviewer found the record indicates that the enrollee has irritable bowel syndrome and fibromyalgia. The enrollee underwent endoscopy more than two (2) years ago. The enrollee has developed more abdominal bloating and is being treated.
The provided record does not support the medical necessity and reasonableness, as defined by Medicare rules, for the enrollee's condition. The elements of the coverage criteria are not satisfied. 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 the CT, thorax, diagnostic; with contrast material(s) (CPT code 71260), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.

You asked the Plan to pre-approve Aduhelm. You say that the requested Aduhelm is medically necessary. The Plan denied your request. The Plan says the requested Aduhelm is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Aduhelm. Our reviewer says that the requested Aduhelm is not medically necessary. Our physician reviewer found the record documents that the enrollee has chronic slowly progressive short-term memory loss. Mental status neurologic examination is noted to be normal. A single MMSE result of 26 is noted which is indicative of normal cognitive function without dementia. An MRI demonstrates chronic microvascular disease and is also suggestive of amyloid angiopathy. The beta amyloid 42/40 ratio is less than 0.058. The record does not indicate that there is objective evidence of cognitive impairment. The elements of coverage rule are not satisfied. The requested service is not recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (26356) provided February 3, 2021.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services
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 26356 is Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no mans's land); primary without free graft, each tendon. We find that CPT code 26356 is not supported in the medical record. Specifically, the operative report does not document an incision over the medial phalanx or that the tendon was repaired or advanced. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met.
Therefore, we decided that the Plan does not have to pay for surgical services (26356) provided February 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.
You asked the Plan to pre-approve the inpatient mental health services. You say that the inpatient mental health services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health services.
Our reviewer says that the inpatient services are not medically necessary. Our physician reviewer found this patient does not continue to meet the criteria for treatment in an acute inpatient mental health treatment and could be treated in a lesser restrictive setting as he is not showing any suicidal or homicidal ideation. The record shows the patient is cooperative and compliant while not showing any acute threats to safety. 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 mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the enrollee is unable to ambulate when discharged home and is at risk of severe falls which could lead to readmission or death. The Plan denied your request. The Plan says the stay is not medically necessary.
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 there are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device (C2624).
You asked the Plan to pre-approve the CardioMEMS device. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 CardioMEMS device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found while the record shows that the enrollee is a Class III heart failure patient, the record does not indicate that the enrollee has ever been hospitalized for heart failure. This is required for this procedure to be 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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device (C2624).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from January 14, 2021, to January 18, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because you should not owe a copayment with this Plan. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for inpatient hospital care.

You have been asked to pay the allowed amount of $71.70, which is less than the $200 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 copayment for an inpatient hospital stay provided from January 14, 2021, to January 18, 2021.
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 medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the medical necessity for admission to acute inpatient rehabilitation is not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 additional home health physical therapy visits.
You asked the Plan to pre-approve 14 additional home health physical therapy visits. You say that the 14 additional home health physical therapy visits are medically necessary. The Plan denied your request. The Plan says the 14 additional home health physical therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 14 additional home health physical therapy visits. Our reviewer says that the 14 additional home health physical therapy visits are not medically necessary. Our physician reviewer found the documentation doesn't support that the member requires additional skilled rehab services to provide treatment that is medically necessary. The member does not require skilled rehabilitation services to effectively provide treatment, care, and/or services in order to improve the
member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 14 additional home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 14 additional home health physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral breast implant removal and reimplantation
(CPT code 19371), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the request is for removal only of the breast
implants and not reimplantation. You state the enrollee has a Grade 4 capsular contracture and rupture
identified on the enrollee's magnetic resonance imaging (MRI) of August 3, 2021. You state the ruptured
implants should be removed as soon as possible. The Plan denied your request. The Plan says there is no
documentation of breast cancer, trauma or the need for improvement of functioning of a malformed body
member necessitating the original surgery. The Plan states it would thus be considered cosmetic and the denial
is upheld.
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 surgery. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the record indicates that the enrollee underwent cosmetic breast augmentation in the 1970's.
The record indicates that the enrollee now has implant rupture on the right. The original surgery was for
cosmetic purposes. Expenses incurred in connection with such surgery are not a covered service. The elements
of the coverage criteria are not satisfied. The requested service is not recommended.
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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve bilateral breast implant removal and reimplantation (CPT code 19371), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120) and collection and application of autologous blood concentrate product (D7921).
You asked the Plan to pre-approve the dental services. You say that the tooth is infected and needs to come out. The partial must come out to repair the anchor tooth. If this is not done you will continue to have pain and the infection will get worse. The Plan denied your request. The Plan says this service is not covered under the Plan benefits.
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. The health plan contract says that any service not listed is not covered.
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 pre-approve fixed partial denture sectioning (D9120) and collection and application of autologous blood concentrate product (D7921).
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an 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 LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. You are 
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are 
not available at the present setting where you are currently receiving care. There are no services available at the 
LTACH that you require that are not available at the health care setting being offered by the health plan. 
 
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

You asked the Plan to pre-approve inpatient hospital care for detox. You say that the requested inpatient hospital care for detox is medically necessary. The Plan denied your request. The Plan says the requested inpatient hospital care for detox is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient hospital care for detox. Our reviewer says that the requested inpatient hospital care for detox is not medically necessary. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. This enrollee was treated under an individualized treatment plan found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review of the records provided, for the admission of this enrollee does not meet the criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others but was without agitation or aggression and without perceptual disturbance including auditory or visual hallucinations. He was not showing any active signs of withdrawal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care for detox have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care for detox.