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

We decided that the Plan does not have to pre-approvea cell therapy injection.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says theservices are not covered.The Plan must follow Medicare rules. Medicare rules say that cellular therapy is denied as not medically necessary.We looked at the file and Medicare rules. The services at issue are a cellular therapy injection. These services are denied by Medicare as not medically necessary.Therefore, we decided that the Plan does not have to pre-approvea cell therapy injection
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 have COVID worries. 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
requested IRF care is not medically necessary. Our physician reviewer found you were admitted to the hospital
on December 3, 2020 with weakness. You are now walking 14 feet with a rolling walker and assistance. You
do not require the intensity of services provided at an IRF. Specifically, the records do not support that you
would be able to tolerate 15 fifteen hours per week of rehabilitative services with regular physician evaluation.
The IRF services are not reasonable or 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 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 Planhasto pay forthe acute inpatient hospital care provided from.You asked the Planto pay foracute inpatient hospital care. You say that this is medically necessary.The Plandenied your request. The Plansaysthatunder Medicare, this request 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 he record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 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 Planhas to pay forthe acute inpatient hospital care provided from.
If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approvean acute  inpatient  rehabilitation  facility  (IRF)  admission and services.You asked the  Plan to pre-approveIRF care. You  say that an acute  inpatient  rehabilitation  facility  admission  is medically  necessary.The  Plan  denied  your  request.  The  Plan  says that you  do not meet  the  criteria  for coverage of an acute inpatient  rehabilitation  facility  admission.The  Plan  must  follow  Medicare  rules.  The  rules  say that an 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  youdo not require  the intensity  of  services  provided  at an inpatient  rehabilitation facility.  Specifically, you  are not  shown  to require,  or to be able  to currently  tolerate,  fifteen  hours  per week of rehabilitative  services  with  regular  physician  evaluation. Yourneeds can be met  at a lower  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-approvean acute  inpatient  rehabilitation  facility  (IRF)  admission  and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint injections for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no trial of physical therapy.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, there is no documentation indicating there have been at least three months of moderate to severe pain that has not responded to conservative care. The pain is associated with radiculopathy and there is no documentation that the facet joint is the main source of pain. The review has determined that the requested lumbar facet joints are not medically necessary or 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint injections for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea replacement rollator.You asked the Plan to pre-approvea replacement rollator. You say that the brakes and seat are worn on your current rollator.The Plan denied your request. The Plan says your current rollator is less than 5 years old and still under reasonable useful lifetime.The Planmust follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a rollator. Yourrollator serves the same purpose as thereplacement rollatorat issue.The documentation submitted does not show that your rollator is irreparably worn, irreparably damaged, or that you have had a change in medical condition to warrant a replacement rollator. Therefore, we decided that the Plan does not have to pre-approvea replacement rollator.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from June 19, 2020 to July 7, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were billed incorrectly.
The Plan must follow Medicare rules. The rules say that HH PPS claims must report a 0023 revenue code line on which the first four positions of the HIPPS code match the code submitted on the RAP. We looked at the file and Medicare rules. The file shows that the claims were not billed with the correct revenue code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from June 19, 2020 to July 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.
You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational, as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature.
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 spacer. Our reviewer says that the requested spacer is not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed. 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 spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea sterling silver Medical ID bracelet.You asked the Plan to pre-approvethe medical ID bracelet. You say that you would like reconsideration because you have a metal allergy and need this bracelet in case of an emergency.The Plan denied your request. The Plan says the requested equipment is an item of convenience and not a Medicare covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea sterling silver Medical ID bracelet
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional mileage for routine transportation.You asked the Plan to pre-approvethe additional mileage. You say that you were told you could be taken to this doctor.The Plan denied your request. The Plan says this request is not covered by your plan.Medicare does not cover transport in a vehicle that is not an ambulance. However,the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 50 miles per one-way trip. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the requested additional mileage will exceed the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional mileage for routine transportation
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision care provided on August 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for vision care. You say that you have established care with this provider before. You say that these services were not denied in the past. The Plan denied your request. The Plan says prior authorization was not obtained.
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 vision care provided on August 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99222) provided on May 25, 2019.
You asked the Plan to pay for initial hospital care. You say that these medically necessary services were
provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not
been met.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for initial hospital care was not filed until June 29, 2020. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for initial hospital care (99222) provided on May 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approveacute  IRF admission  and  services.You asked the  Plan to pre-approveIRF care. You  say that the  enrollee  meets  the full  criteria  for  an inpatient rehabilitation  stay.The  Plan  denied  your  request.  The  Plan  says the criteria  for admission  to the Acute  Inpatient Rehabilitation  setting  have  not been 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  above.We asked our physician  reviewer  to carefully  review  the  case file  and apply  the  relevant  Medicare  rules  to determine  if  the Plan  was correct in  denying  the  request  to pre-approve  IRF care. Our reviewer  says  that  the requested  IRF care is  not considered  medically  reasonable  and necessary  based on Medicare  guidelines.  Our physician  reviewer  found  the complexity  of  the enrollee's  nursing,  medical  and rehabilitation  needs does not require  an acute  hospital  inpatient  stay  with  an interdisciplinary  approach  to rehabilitation  care. Our reviewer found  that  the  enrollee  does not require  treatment  by multiple  therapies,  including  either  physical  therapy  or occupational  therapy,  and an intensive  rehabilitation  therapy  program.  The  medical  record supports  a need for physical  and occupational  therapy,  but  it  does not support  a need for an  intensive  rehabilitation  therapy program.  Our physician  reviewer  also  found  that  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-approveacute  IRF admission  and  services.
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. You say that the IRF care requested is medically necessary.The Plan denied your request. The Plan says the rules for IRF care have not been 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 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy,but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approveCardioMEMS.You asked the  Plan to pre-approveCardioMEMS.  You say that you  would  like  the  plan  to reconsider  their denial.The  Plan  denied  your  request.  The  Plan  says the requested  services  are 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  CardioMEMS.  Our reviewer  says  that the  requested  items/services  are not  considered  medically  reasonable  and  necessary  in  this  case. Our physician reviewer  found  the  enrollee  has  NYHA Class  III congestive  heart  failure  with  reduced  LV ejection  fraction (LVEF  25%) requiring  hospital  admission.  CardioMEMs  device  has been  demonstrated  in  only  one randomized  prospective  trial  to help  reduce  hospital  readmission  compared  to standard  medical  therapy.   Moreover,  concerns  have  been raised  about potential bias  in  this  trial  calling  into  question  the  results. Therefore,  the  efficacy  of  the CardioMEMS  device  is uncertain  at this  time  according  to leading  authorities  and not recommended  in  current  guidelines  for the  treatment  of  heart  failure.  The  device  should  still  be considered experimental  or investigational.  Therefore,  the  enrollee  does not meet  criteria  for the  requested  services.We looked  at this  physician's  review,  the  file,  and  Medicare  rules.  Based on this  information,  we decided that Medicare  rulesfor coverage  of CardioMEMS  have  not  been met.Therefore,  we decided that  the  Plan  does not have to pre-approveCardioMEMS.
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. You say that the services are medically necessary.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 requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on December 6, 2020 with a cerebrovascular accident and expressive aphasia. The physical therapy note dated December 9, 2020 states she needs contact guard assist to walk 300 feet using a two wheeled walker. She does not require the intensity of services provided at an IRF. Specifically, she is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation.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: 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 takes two people to transfer the enrollee to bed and
she is only able to take two steps on her own. You say that it would be best for the enrollee to receive intense,
aggressive therapy so that she can progress to at least a one-person transfer and return home safely with her
family. You say that the enrollee has been making improvements, her cognitive ability has returned, and she is
making progress with her strength. The Plan denied your request. The Plan says an IRF is not medically
necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for altered mental status and was treated for a stroke. The enrollee's medical problems are stable.
There are no identified problems that need inpatient medical management. There are no complex nursing or
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports
a need for physical and occupational therapy, but it does not support a need for an intensive rehabilitation
therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and
benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.