Persius/hicric huggingface dataset:
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 it is felt that care in the LTACH setting would lead to better outcomes for this enrollee. The Plan denied your request. The Plan says there is no clinical advantage to LTACH over remaining in the current facility.

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 Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. In this case, ongoing care needs include tracheostomy care, intravenous antibiotics, surveillance laboratory studies, wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wrist hand finger orthosis (CPT Code
L3808) provided on July 8, 2020.
You asked the Plan to waive the coinsurance for the orthosis. You say that you got a bill for a plastic thing they
made to go around your finger and you did not even use it as it was too hard and did not fit right. The Plan
denied your request. The Plan says the claim was processed accordingly with your 2020 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 a wrist hand finger orthosis (CPT Code L3808) on July 8, 2020. You
are asked to pay 20% coinsurance for the orthosis. Your EOC states that enrollees must pay 20% coinsurance
for DME and related supplies. 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 coinsurance for wrist hand finger orthosis
(CPT Code L3808) provided on July 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe 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 review has determined that there is no documentation provided necessitating admission to a LTACH. The enrollee still is requiring acute hospital level of care services and is receiving appropriate care at the present acute care hospital.The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approveLTACH services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional inpatient psych treatment.You asked the Planto pre-approvethe additional treatment. You say that this is medically necessary.The Plandenied your request. The Plansaystreatment can happen in a lower level of care, such as outpatient treatment.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 additional treatment. Our reviewer says that the requested additional treatment is not medically reasonable or necessary. Our physician reviewer found it is not expectedthat this enrollee would improve in a reasonable period of time beyond the dates in question, as he was not showing any dangerousness to self or others. There were no auditory or visual hallucinations or aggressive behaviors. There were no acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate.
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 additional treatment have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional inpatient psych treatment.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trintellix 5mg tablet.

You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Trintellix 5mg tablet.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skill nursing and aide services.
You asked the Plan to pre-approve the services. You say that you are having a hard time getting around the
house and you do not know how to do things for yourself. The Plan denied your request. The Plan says they do
not have a physician order or a Plan of Care for home health services and a certification that you are confined
to the home.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 services. Our physician reviewer
found in order to require Home health care skilled services, you must be confined to the home, under the care
of a physician, and receiving services under a plan of care established and periodically reviewed by a
physician. Additionally, you must be in need of skilled nursing care on an intermittent basis or physical
therapy or speech-language pathology; or have a continuing need for occupational therapy. Being homebound
means leaving home is a major effort. In this case, the documentation doesn't support that you are home bound
and are confined to the home. There is no indication that skilled care is required to provide treatment that is
medically necessary or to provide a maintenance program or maintain your condition and/or prevent
deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or
hospitalizations. There is no clear decrease in level of function.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve home health skill nursing and aide services.
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 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 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to currently tolerate, fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR).We looked atthis 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 IRF care is medically necessary.The Plan denied your request. The Plan says coverage criteria 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 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 documentation does not support that the enrollee continues to require an acutehospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's needs canbe 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair with components for the enrollee.You asked the Plan to pre-approvethe wheelchair. You say that this is medically necessary.The Plan denied your request. The Plan says the request is for a group 2 chair, but the invoice is for a group 3 chair.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if thepatient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the requested Group 3 power wheelchair on the invoice is covered when the enrollee's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity. The documentation from the enrollee's treating medical practitioner does not indicate a neurological condition. There is no documentation of a 
myopathy or congenital skeletal deformation in the submitted medical progress reports that support the requested  Group 3 power wheelchair (K0843).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 wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea power wheelchair with components for the enrollee
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to reduce the copayment for anx-ray provided by a participating provider on February 21, 2020.You asked the Plan to reduce the copayment for an x-ray. You say that this copayment is too high. The Plan denied your request. The Plan says that the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $14 copayment for outpatient diagnostic tests/x-rays. The Plan says you must pay a $130 copayment for an x-ray. Based on the Plan contract, however, you cannot be asked to pay more than a $14 copayment for an x-ray. Therefore, we decided that the Plan has to reduce the copayment for an x-ray provided by a participating provider on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic services provided on July 15, 2020.You asked the Plan to pay forthis service. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says Medicare and the Plan only covers manual manipulation of the spine. Chiropractic maintenance care is not covered.The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. The Plan can only pay services related to manual manipulation. The services billed by the chiropractor related to maintenance are not covered. Therefore, we decided that the Plan does not have to pay forchiropractic services provided on July 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee would be better served in a slower paced, less intensive rehab program.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of a hip fracture after a fall. 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 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewing x-rays (D0274) provided on August 1, 2020.You asked the Plan to pay forthe bitewing x-rays. You say that you were unaware that you had received this service on January 25, 2020. You also say that you do not understand why the dental office took the images again.The Plan denied your request. The Plan says the frequency limitation for this service 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, bitewings are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0274) on January 25, 2020, and your bitewing x-rays benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe bitewing x-rays (D0274) provided on August 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACHservices.You asked the Plan to pre-approvethe 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 there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approveLTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvepower scooter repair.You asked the Planto pre-approvethe repair. You say that this is medically necessary.The Plandenied your request. The Plansaysthe repair cost exceeds the replacement cost.The Plan must follow Medicare rules. Medicare rules say that DME repair cannot be covered if it costs more than replacing the item. 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 repair. Our reviewer says that the requested repair not considered medically reasonable and necessary in this case. Our physician reviewer found the health plan's decision not to repair the patient's scooter was correct per the Medicare Benefit Policy Manual, Chapter 15, Section 110.2. which states that if the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medial need no payment can be made for the amount of the excess. The total repair cost is $1,326. The replacement cost would be $1,292.77. The repair cost exceeds replacement in this case therefore the Medicare criteria have not been met.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the repair have not been met.Therefore, we decided that the Plandoes not haveto pre-approvepower scooter repair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plandenied 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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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-approveLTACH services.