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

We decided that the Plan does not have to pre-approve the acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you need acute physical therapy. The Plan denied
your request. The Plan says your ongoing skilled therapy and nursing needs can be provided at 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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. You do 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. Our physician reviewer also found that there is not a reasonable expectation that you
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve the acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit provided on February 1, 2021.
You asked the Plan to pay for the office visit. You say that the enrollee was advised her visit would be covered. The Plan denied your request. The Plan says that services rendered by non-participating providers require prior authorization.
The Plan must follow Medicare rules. Medicare rules say that plans can require enrollees to get care from network providers. The Plan contract says that you can get your care from an out-of-network provider. We looked at the file and the rules. Although the enrollee received care from an out-of-network provider, the Plan allows services from out-of-network providers. There is no indication the provider is unable to render services under Original Medicare. Based on this information, we decided that Medicare rules for coverage of the office visit have been met. Therefore, we decided that the Plan has to pay for the office visit provided on February 1, 2021.
If the Plan does 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/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not require daily skilled nursing and/or skilled therapy 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 SNF admission have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means admission into a SNF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (93970) provided on August 24, 2020.
You asked the Plan to pay for the duplex scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent. There were network providers available.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 for a duplex scan (93970) provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve ophthalmology services. You say that your doctor recommended this provider. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.
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 records provided support the need for care in an LTACH. The Plan denied your request. The Plan says the enrollee is not medically stable to transfer to another level of care. The Plan says that the enrollee can safely receive the care needed in the current hospital setting.

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 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-approve long term acute care hospital (LTACH) 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 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 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 surgical repair of a tib-fib fracture and non-operative management of rib fractures after a fall. 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: 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 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 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 coronary artery bypass grafting in May 2021 and is currently living at home with continued weakness and trouble with ambulation. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic knee surgery provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an out-of-network orthopedic knee surgeon. You say that the Plan does not offer orthopedic knee surgery and you would like to go to an out-of-network provider as they specialize in the surgery. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve orthopedic knee surgery provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with an out-of-network provider.

You asked the Plan to pre-approve the office visit. The Plan denied your request. The Plan says the provider is out-of-network and in-network providers are available.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit with an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323) and aspiration and/or injection of fluid from large joint (20610).
You asked the Plan to pre-approve Euflexxa and aspiration and/or injection of fluid. The Plan denied your request. The Plan says the step therapy criteria for Euflexxa have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Euflexxa and aspiration and/or injection of fluid. Our reviewer says that Euflexxa does not meet coverage criteria. Our physician reviewer found the Plan requires a trial of drug Synvisc, Durolane, and Gelsyn-3 before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. Our reviewer also found that there is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa and aspiration and/or injection of fluid have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323) and aspiration and/or injection of fluid from large joint (20610).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for medication therapy management (99606 and 99607) provided on October 20, 2020, through January 16, 2021.

You asked the Plan to pay for the medication therapy management. You say that you would like reconsideration because this service has been helpful to control your pain. The Plan denied your request. The Plan says this service is not a Medicare covered benefit.

The Plan must follow Medicare rules. Medicare rules say plans must pay for a medical service or item if regular Medicare would pay for it in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medication therapy management have not been met. Specifically, medication therapy management services are not covered under Medicare Part B. Therefore, we decided that the Plan does not have to pay for medication therapy management (99606 and 99607) provided on October 20, 2020, through January 16, 2021.

Benefits for the medication therapy management 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous process distraction device procedure.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). You say that the enrollee has suffered, and her condition has greatly impacted her quality of life. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.

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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process distraction devices remain experimental at this time. More research is needed to show safety and efficacy of the devices.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous process distraction device procedure.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on October 28, 2020.
You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). You say that the ambulance services were medically necessary. The Plan denied your request. The Plan says the ambulance transport was not medically necessary. The enrollee could have been safely transported by another type of motor vehicle, possibly a van transport vehicle.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. 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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the enrollee is an 81-year-old female who requested ambulance services for flu-like symptom and fever, cough, muscle cramps, recently tested positive for
COVID-19. Emergency Medical Services (EMS) arrived, and the patient was hemodynamically stable with normal vitals and she was not in any significant distress and was not hypoxic. She was transported to the hospital without incident. The enrollee's presenting symptoms did not meet a prudent layperson's criteria for emergency care. The documentation does not support that other means of transport, such as a stretcher van, would be contraindicated. The documentation does not support that the enrollee required expertise, services, and special equipment in an ambulance. The documentation does not support that the ambulance transport to the hospital on October 28, 2020 was medically reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, advanced life support, emergency transport, level 1
(A0427, A0425) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on October 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that you suffer from lymphedema and without the stockings, you cannot get the compression needed to keep blood circulating in your legs and feet. You experience extensive pain in your legs and feet, and they help with the pain. The Plan denied your request. The Plan says the requested stockings is not a Medicare covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.