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 for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires ventilator weaning.The Plan denied your request. The Plan says that the enrollee's complex medical needs are being met in the current acute setting at this time.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. The enrollee was admitted to the acute care hospital on 6/16/20 following thoracic endovascular aortic repair (TEVAR) which was complicated by multiple strokes and a large hematoma. A tracheostomy and a PEG tube have been placed. The enrollee has persistent severe encephalopathy related to her multiple bihemispheric strokes. It is documented that the enrollee has been without purposeful neurologic activity since admission. 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. The member is receiving acute hospital care, and acute care services have not been denied. 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 she 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays, four 2D oral/facial photographic images, panoramic x-ray, periodontal scaling and root planing of four or more teeth, two periodontal scalings and root planings of one to three teeth per quadrant, oral hygiene instructions, two periodontal procedures, and two gingival irrigations provided on February 10, 2020.
You asked the Plan to pay for the dental services. You say that you received x-rays at this visit and were told you needed extensive treatment because you continue losing your teeth. You also say that these procedures are not cosmetic, but medically necessary. The Plan denied your request. The Plan says these services are not covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays, four 2D oral/facial photographic images, panoramic x-ray, periodontal scaling and root planing of four or more teeth, two periodontal scalings and root planings of one to three teeth per quadrant, oral hygiene instructions, two periodontal procedures, and two gingival irrigations provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider from February 18, 2020. to February 24, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 servicesat issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to theenrollee by an out-of-network provider from February 18, 2020. to February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says care can be received in another setting.
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 your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require an
intensive inpatient rehab therapy program. Based on the medical records provided, there is concern that you
will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in
an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in
this case.
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the declot vascular device procedure provided on February 11, 2020.You asked the Plan to waive the copayment for the declot vascular device procedure. You say that you do not believe this procedure should be coded as a minor surgery. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $250 copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $250 copayment for the declot vascular device procedure. The declot vascular device procedure falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows that the declot vascular device is considered a surgical procedure.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 declot vascular device procedure provided on February 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on September 24, 2019.
You asked the Plan to pay for the ambulance transport from dialysis. You say that the transport was medically necessary. The Plan denied your request. The Plan says the enrollee could have been transported by another type of vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ambulance transport from dialysis. Our reviewer says that the service was not medically necessary. Our physician reviewer found the enrollee was transported between a skilled nursing facility and a dialysis center. The enrollee was noted to be ambulatory using a rolling walker. Documentation does not support the enrollee was unable to sit safely or outline why alternate modes of transport were not considered. Without the support of the documentation, Medicare criteria were not met. The denial is upheld. 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 ambulance transport from dialysis have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport provided on September 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.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 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 respiratory support with humidified air over tracheostomy mask, telemetry, surveillance laboratory studies, tube feedings, tight glucose control, 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. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT).
You asked the Plan to pre-approve SBRT. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 SBRT. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee is not a candidate for resection and cryoablation was attempted but unable to be performed. SBRT is an accepted alternative based on published data and ASTRO Model policy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT).
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 need to get out of the hospital due to COVID-19 and need to go to a high intensity IRF. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are mostly moderate assistance for functional transfers and activities of daily living. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, predicted period. An IRF intensity of care is not warranted. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on September 21, 2019.
You asked the Plan to pay for the ambulance transport to dialysis. You say that the transport was medically necessary. The Plan denied your request. The Plan says the enrollee could have been transported by another type of vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ambulance transport to dialysis. Our reviewer says that the service was not medically necessary. Our physician reviewer found the enrollee was transported between a skilled nursing facility and a dialysis center. The enrollee was noted to be ambulatory using a rolling walker. Documentation does not support the enrollee was unable to sit safely or outline why alternate modes of transport were not considered. Without the support of the documentation, Medicare criteria were not met. The denial is upheld. 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 ambulance transport to dialysis have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport provided on September 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional routine transportation trips. You say that it is medically
necessary to continue receiving medical transportation to and from dialysis on a weekly basis. The Plan denied
your request. The Plan says the benefit for routine transportation services has been exhausted.
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 trips per year.
We looked at your request, the records in the case file, and the rules. The records show that 50 one-way routine
transportation trips have been covered for the 2020 calendar year. Based on this information, we decided that
you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided
that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block (64454).You asked the Plan to pre-approve genicular nerve block. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 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 genicular nerve block. Our reviewer says that the requested items/services are not consideredmedically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limitedto any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve block is not reasonable or 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 genicular nerve block have not been met.Therefore, we decided that the Plan does not have to pre-approvegenicular nerve block (64454).
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 appears to still require ongoing acute care at the current setting. There was insufficient support suggesting the enrollee would require at least 25 days of additional acute care management to justify transfer to an LTACH. The enrollee does not appear to require services at the proposed LTACH that are not already available at the current acute care hospital. If additional acute care is needed, they could be administered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a lower level of care when more stable appears most appropriate based on the provided documentation. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were unconscious and your husband
could not wake you up. You say that the responding paramedics spent hours reviving you and making sure that
you were okay. You stated that you are disappointed with the Plan's decision to not pay for the services. You
say that you have paid your insurance for over forty years and have never missed a payment. You asked the
Plan to reconsider their denial. The Plan denied your request. The Plan says these services are not a covered
benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on February 3, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the shower chair is necessary for you. You say that you are prone to dropping or sliding on the floor when it is wet. You stated that the requested shower chair is needed for your safety and to avoid a potential accident. You say that you need to sit while showering and you asked the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.