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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. The Plan denied your request. The Plan says the enrollee has achieved improvement with physical therapy and her level of function is at the point where a continued IRF stay is not appropriate or beneficial. The Plan says that the enrollee's more appropriate for placement in a lower level of care.
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 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 syncope, a fall, and stroke. The enrollee's medical conditions are stable. 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 enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy provided from April 28, 2020, through June 1, 2020.

You asked the Plan to pay for medical nutrition therapy services. The Plan denied your request. The Plan says the enrollee has a limited benefit of 3 hours of therapy the first year and 2 hours of therapy the second year. A doctor's order for is required for this therapy. This service was provided by a non-contracted provider. That provider did not get approval for this therapy. The therapy provider has not given us any records. We do not have an order from the enrollee's doctor for this therapy. We do not know if the enrollee has already had the maximum therapy allowed.

The Plan contract says that the Plan covers 3 hours of one-on-one counseling services during the first year that the enrollee receives medical nutrition therapy services under Medicare and 2 hours each year after that. If the enrollee's condition, treatment, or diagnosis changes, the enrollee may be able to receive more hours of treatment with a physician's referral. A physician must prescribe these services and renew their referral yearly if the treatment is needed into the next calendar year.

We looked at the file and the Plan's rules. The file shows that the necessary requirements for medical nutrition therapy have not been met. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy provided from April 28, 2020, through June 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 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 in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee does not require the intensity of services provided at an IRF.

Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs 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-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (71045) provided on March 6, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed on a duplicate claim.

The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one previously processed and paid by the Plan. Duplicate claims are not payable. 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 pay for the services (71045) provided on March 6, 2021.
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).

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.

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 you appear to be improving, and additional short-term acute care services are required and can safely be received at the current facility until able to transfer to a lower level of care. You do require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time until the acute care treatment has completed.

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 admission to a long term acute care hospital (LTACH).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inhalation of nitrous oxide/analgesia (D9230).
You asked the Plan to pre-approve the inhalation of nitrous oxide/analgesia. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not a covered benefit.
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 pre-approve the inhalation of nitrous oxide/analgesia (D9230).
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 a LTACH admission is medically
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for
coverage of a LTACH admission.

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 that in this case, the enrollee was admitted with sepsis due to pneumonia. The case
file indicates that the enrollee is receiving acute care services that have not been denied. The case file does not
indicate that the enrollee requires acute care services that he is not currently receiving that would be available
at the LTACH facility. The elements of the coverage rule 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466).
You asked the Plan to pre-approve a home ventilator. You say that you require a ventilator to prevent deterioration and further harm. The Plan denied your request. The Plan says the requested device is being as a bilevel positive airway pressure device rather than a ventilator.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a home ventilator. Our reviewer says that the requested item is not medically necessary. Our physician reviewer found that your diagnosis is chronic obstructive pulmonary disorder (COPD), but there is no documentation of carbon dioxide (CO2) retention. The ventilator is being used in average volume-assured pressure support (AVAPS) mode, which can be provided by certain bilevel positive airway pressure (BiPAP) devices. Medicare does not cover a home ventilator when used as BiPAP.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha.
You asked the Plan to pre-approve Repatha. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Repatha.
Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF services after June 12, 2021.
You asked the Plan to pre-approve continuation of SNF services. You say that your balance is off, and you cannot manage at home safely. The Plan denied your request. The Plan says you are functional at a high level and your ongoing needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve continuation of SNF services. Our
reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based
on the documentation provided, you no longer qualify for SNF coverage. You do not have documented skilled
nursing needs. You do not have documented skilled therapy needs. You are ambulating more than 100 feet and
tending to activities of daily living independently. Daily skilled services are not required to establish a
maintenance program or to prevent deterioration of your condition. You care needs, as a practical matter, can
be provided at a lower level of care (ex. home, assisted living, long-term 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 continuation of SNF services have not been met. Therefore, we decided that the
Plan does not have to pre-approve continuation of SNF services after June 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a basket for a scooter.
You asked the Plan to pre-approve a basket for a scooter. You say that without the requested item you cannot be independent and you cannot depend on anyone. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
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-approve a basket for a scooter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on December 17, 2019.

You asked the Plan to waive the coinsurance for the Part B drug. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received Part B drugs on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.

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 20% coinsurance for Medicare Part B prescription drugs.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received Part B drugs on December 17, 2019. You have been asked to pay a 20% coinsurance for the Part B drug, totaling $61.23. The Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance for the Part B drug provided on December 17, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Privigen.

You asked the Plan to pre-approve the Privigen. You say that the clinical documentation provided supports the use of the rug being requested. The Plan denied your request. The Plan says the requested drug is not medically reasonable and 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 the Privigen. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of Calcinosis cutis. The documentation does not support that the requested drug is medically necessary. Calcinosis cutis is not an FDA-approved indication for Privigen. There is no documentation that supports the requested drug is safe and effective for the enrollee. There are not two-Phase III clinical trials that definitively demonstrate the safety and effectiveness of Privigen for the treatment of Calcinosis cutis. There are not at least two-Phase II clinical trials with reasonably large patient samples that show consistent results of safety and efficacy for the use of Privigen for the treatment of Calcinosis cutis. The use of Privigen for the treatment of Calcinosis cutis is not an accepted standard of medical practice. There are no published recommendations from specialty societies or in other authoritative evidence-based guidelines regarding this treatment. 

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 Privigen have not been met. Therefore, we decided that the Plan does not have to pre-approve Privigen.
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 is felt that IRF care would be medically reasonable and necessary. The Plan denied your request. The Plan says the enrollee does not require therapy in the IRF 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 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 the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the pelvis.
You asked the Plan to pre-approve an MRI of the pelvis. You say that this imaging should be done before invasive endoscopic intervention. The Plan denied your request. The Plan says this is medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the pelvis. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found the medical record indicates that an MRI of the abdomen is desired to evaluate bile duct dilation following cholecystectomy. The provided records do not support the medical necessity or reasonableness of the requested pelvic MRI. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator used with a non-invasive interface represented by current procedural terminology (CPT) code E0466.
You asked the Plan to pre-approve the home ventilator. You say that you returned the ventilator and then realized that you need it for your health. The Plan denied your request. The Plan says the requested device is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is considered not medically necessary in this case. The enrollee has COPD, but there is no documentation of an arterial blood gas, while the enrollee is in a stable state, showing CO2 retention. Some BiPAP devices are capable of providing the AVAPS mode of support that has been ordered for the ventilator, at less cost, and Medicare does not cover a ventilator when used as BiPAP. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator used with a non-invasive interface represented by current procedural terminology (CPT) code E0466.