Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve general anesthesia - first 15 minutes (D9222) and general anesthesia - each subsequent 15-minute increment (D9223).
You asked the Plan to pre-approve general anesthesia - first 15 minutes and general anesthesia - each subsequent 15-minute increment. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are 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 general anesthesia - first 15 minutes (D9222) and general anesthesia - each subsequent 15-minute increment (D9223).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve continued SNF care. You say that continued inpatient skilled nursing facility care is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of continued inpatient skilled nursing facility 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 continued SNF care. Our reviewer says that continued inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that you do not have documented skilled nursing or skilled therapy needs. You are ambulating more than one hundred feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.

The Plan must follow Medicare rules. The rules say that Medicare pays for an evaluation and management service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier "-57" to indicate that the service resulted in the decision to perform the procedure.

We looked at the file and Medicare rules. Billed code 99221 (initial hospital care) was billed with modifier -57. The records do not show that the services were separately identifiable from the services related to the subsequent surgical service. Payment is included in the global surgical package. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to pre-approve SNF care. We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve SNF care. You say that the SNF services are medically necessary. The Plan says that the enrollee does not meet criteria for the requested SNF services.

We decided that the Plan has to pre-approve SNF services.

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 care. Our reviewer says that based on the documentation provided, the enrollee qualified for SNF coverage. Our physician reviewer found during this time, the enrollee did not have documented skilled nursing needs, but he did have documented skilled therapy needs and showed signs of progress until he was discharged from PT.

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 care have been met. Therefore, we decided that the Plan has to pre-approve SNF services.

We also decided that the Plan does not have to pre-approve SNF services.

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 services. Our reviewer says that based on the documentation provided, the enrollee did not qualify for SNF coverage. Our physician reviewer found during this time, the enrollee did not have documented skilled nursing needs or documented skilled therapy needs.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.

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) care.

You asked the Plan to pre-approve SNF care. 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper endoscopy.

You asked the Plan to pre-approve upper endoscopy. 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 follows Medicare rules. Medicare rules say that endoscopy procedures can only be allowed if abnormal signs or symptoms or known disease are present.

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 upper endoscopy. Our reviewer says that the services are not medically necessary. Our physician reviewer found coverage indication is not met for EGD based solely on anemia having been historically found 9 months ago, and without a current colonoscopy report negative for a source of presumptive GI blood loss.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of upper endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve upper endoscopy.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for IRF admission.

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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee needs ongoing close monitoring with regard to her anemia as well as her renal function/dialysis needs. Her last transfusion was on 03/16/2021 (the same day as the initial request for the inpatient rehabilitation transfer) and her dialysis needs are being re-evaluated on a day-by-day basis. The enrollee does require physical therapy and occupational therapy services as provided in an intensive inpatient rehabilitation therapy program. There is documentation that the enrollee can participate in and requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 

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 been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

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 an inpatient skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility 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 inpatient skilled nursing facility admission.

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 care. Our reviewer says that an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that the enrollee does not have documented skilled nursing or skilled therapy needs. The enrollee is ambulating more than one hundred feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a penile prosthesis.

You asked the Plan to pre-approve prosthesis. You say that this is medically necessary. The Plan denied your request. The Plan says that labs were not provided to support the need for an implantable device.

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 prosthesis. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found an inflatable penile prosthesis is an appropriate and indicated treatment for this patient with severe erectile dysfunction. He has failed PDE5i and the most potent injectable (quad mix). Intra-urethral suppositories (MUSE) are no longer available and a vacuum erection device will not be effective. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prosthesis have been met. Therefore, we decided that the Plan has to pre-approve a penile prosthesis.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint nerve destruction for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary for suffering from chronic axial back pain thoracic and lumbar region. The Plan denied your request. The Plan says the records do not show a current pain score.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has only had one set of diagnostic medial branch blocks and does not have any unstable medical conditions. The request is not medically reasonable or necessary. Additionally, there is no indication for monitored anesthesia 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint nerve destruction for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided on December 12, 2019.

You asked the Plan to pay for a pneumatic compression device (E0676). You say that the physician ordered this medically necessary equipment so the Plan should pay this claim. The Plan denied your request. The Plan says the device was ordered for a preventative function.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided on December 12, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET scan for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary to rule out the possibility of a new primary malignancy. The Plan denied your request. The Plan says that there have been more than three PET scans.

The Plan must follow Medicare rules. Medicare rules say that PET scans are medically indicated when used to guide subsequent treatment decision making.

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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found PET scans are medically indicated when used to guide subsequent treatment decision making. This patient has a new right lower lung nodule measuring 1.3 cm after stable disease. If PET positive SBRT would be considered. The service is reasonable and medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scan have been met. Therefore, we decided that the Plan has to pre-approve a PET scan for the enrollee.

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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient psychiatric care from March 12, 2021 and forward.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the continued inpatient psychiatric care from March 12, 2021 and forward is medically necessary. The Plan denied your request. The Plan says that the continued inpatient psychiatric care from March 12, 2021 and forward is not medically necessary.

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 inpatient psychiatric hospital services. Our reviewer says that the continued inpatient psychiatric care from March 12, 2021 and forward is medically necessary. Our physician reviewer found the enrollee is with Alzheimer dementia that was admitted from an alternative living facility due to disordered thinking, aggressive behavior, and thoughts of harming herself. According to the portions of the medical record quoted by the plan, beginning March 12, the symptoms improved; namely, there was no longer aggressive behavior towards self or others, and no hallucinations. Other portions of the record indicate that the enrollee was exhibiting confusion and paranoia. In addition, Alzheimer dementia and aggressive behavior was still an ongoing issue. Placement is being sought but due to enrollee's history of aggressive behavior has not been able to be found. I

n this case, there is sufficient documentation that the enrollee still has active psychiatric issues that precludes treatment at a lower level of care. Therefore, continued inpatient psychiatric care is 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 inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve continued inpatient psychiatric care from March 12, 2021 and forward.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the arthroplasty services.

You asked the Plan to pre-approve inpatient hospital services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient hospital services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found inpatient stay is not needed with this routine knee arthroplasty surgery. Observational stay for 48 hours is most appropriate and is the care standard. There are no red flags for inpatient admission documented. Therefore, you do not meet criteria for the inpatient 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the arthroplasty services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for infrared therapy.

You asked the Plan to pay an additional amount for the infrared therapy. The Plan denied your request. The Plan says the claims processed and paid correctly under your Plan's POS benefit.

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 did not pre-approve the infrared therapy. We found no exception that would require the Plan to pay an additional amount for these services. Therefore, we decided that the Plan does not have to pay an additional amount for infrared therapy.