Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood draw and the basic metabolic panel provided on July 2, 2019.
You asked the Plan to pay for the laboratory services. You say that you were in the hospital from June 22, 2019 to June 24, 2019 being treated for a low sodium level. You say that you were instructed to get blood work done in 7 days. You say that you had a pre-scheduled trip to New York and therefore had to get the blood work done there. The Plan denied your request. The Plan says the services were not urgent or emergent. The Plan says that the services could have been foreseen before leaving the service area. The Plan also says the services could have been provided in network.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 laboratory services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee could have foreseen requiring the services prior to receiving his service. The documentation shows that the enrollee was advised on June 24, 2019 that he should have his sodium level checked at the end of the week. The services were received on July 2, 2019 while the enrollee was on a pre-scheduled trip in New York. Therefore, the services were not 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the blood draw and the basic metabolic panel provided on July 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care on 2/5/20 for the treatment of back pain secondary to a subacute T11 fracture and spinal stenosis. She was deemed medically stable and discharged to an assisted living setting on 2/10/20 with home health physical therapy. She was referred for a SNF rehab admission. At the time of discharge from the hospital, the enrollee was requiring minimal assist for bed mobility, transfers with contact guard assist and ambulating 60 feet with contact guard assist and a walker. The enrollee needed moderate assist for bathing and lower body dressing and all others with minimal assist. On 2/21/20, while at home receiving physical therapy (PT) she ambulated 150-200 feet with walker and contact guard assistance. She was able to ambulate 175 feet with contact guard assistance and walker on 2/24/20.
Based on review of the available records, the enrollee does not meet criteria for coverage for an admission to a SNF rehab setting. The enrollee does not require skilled nursing and/or skilled rehabilitation services on a daily basis and these services can be provided in-home. The PT and occupational therapy (OT) services to be delivered in a SNF are not deemed reasonable and necessary for the treatment of a patient's subacute compression fracture at 11 and at the current functional level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a skilled nursing facility (SNF) have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you are covered for up to 24 one-way trips per calendar year. The plan states you have used all 24 one-way trips for the 2020 benefit year and additional trips cannot be approved.
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 24 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics (L3000, L3217). You say that because of medical issues the enrollee needs the orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 2/6/20 for altered mental status. The enrollee has functional quadriplegia due to MS. The enrollee had been inpatient at LTACH for wound care and IV antibiotics treating osteomyelitis and stage IV sacral ulcer. The enrollee's current hospital stay has been complicated by anemia of chronic disease, acute on chronic kidney disease, multi-drug resistant acinetobacter and psuedomonas, protein malnutrition, electrolyte derangements, urinary tract infection, gastritis, toxic metabolic encephalopathy and dehydration. 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 surveillance laboratory studies, fluid balance with diuretics, intravenous antibiotics, wound and wound vacuum care, tube feeding, 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital level of care for approved total knee arthroplasty (TKA) surgery.
You asked the Plan to pre-approve acute inpatient hospital level of care for approved total knee arthroplasty (TKA) surgery. You say that the requested inpatient level of care for the approved TKA surgery is medically necessary. The Plan denied your request. The Plan says the requested inpatient level of care for the approved TKA surgery is 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 acute inpatient hospital level of care for approved total knee arthroplasty (TKA) surgery. Our reviewer says that the requested inpatient level of care for the approved TKA surgery is not medically necessary. Our physician reviewer found this enrollee reportedly has severe right knee pain with giving way and inability to bear weight. She has been approved for an outpatient total knee arthroplasty. Under consideration is a request for inpatient admission for the total knee arthroplasty. The records indicate that inpatient admission had been recommended as she had hypertension.
However, there is no clear documentation of her medical condition in the submitted medical records, or that this would not be appropriately managed in an observation setting. There is no evidence that she would require inpatient admission over observational care. Therefore, the requested inpatient level of care for the approved total knee arthroplasty surgery would not be considered medically reasonable and 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 acute inpatient hospital level of care for approved total knee arthroplasty (TKA) surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital level of care for approved total knee arthroplasty (TKA) surgery.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a stroke, which was complicated by aspiration pneumonia. The enrollee was intubated/ventilated and subsequently received a tracheotomy. He is showing signs of successful ventilator weaning. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve mobile laboratory services to be provided.
You asked the Plan to pre-approve mobile lab services. You say that you are home bound and unable to travel to your doctor's office. You are unable to travel to the laboratory to receive weekly medically necessary laboratory services. The primary care physician uses this provider who have the only mobile laboratory available to come to your home to perform the tests. The Plan denied your request. The Plan says that no clinical information was received about your illness. The only information provided was your diagnosis of arthritis.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not shown that there are in-network providers available to provide the needed care. The record does not show documented attempts of the Plan to retrieve medical records from your primary care physician or any other in-network providers. It is the burden of the Medicare health plan to substantiate the denial with medical evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pre-approve mobile laboratory services to be provided by the requested out-of-network provider.
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 needed emergency assistance because you had fallen and could not get up. You say that you did not need transportation to the emergency room but that you needed transportation to a cardiologist. The ambulance would not take you to specialty care. 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 October 9, 2019. 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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee fell at the gym and was found to have a fracture of the sacrum and pelvis. She was reluctant to go to a skilled nursing facility (SNF). The emergency room doctor had tried to arrange a direct transfer to a rehab facility but this was not successful. She ended up being admitted for observation and pain control. On 2/21/20 in occupational therapy (OT) she was supine to sit moderate assist with gait belt around left lower extremity to mobilize out of bed. She was moderate assist for bed to commode transfer and sit to stand. On 2/22/20 in physical therapy (PT) she is refusing out of bed due to pain. On 2/24/20 the medical progress note indicates the enrollee is appropriate for SNF placement but she only wants a facility close to her home. There are no new complaints. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility therapy program level 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 residential treatment from an out-of-network provider, for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Medicare does not cover Residential treatment facilities and the provider is also out-of-network. Therefore, we decided that the Plan does not have to pre-approve residential treatment from an out-of-network provider, for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Olmesartan-HCTZ for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee has been stable on this medication for years. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Olmesartan-HCTZ for the enrollee.
Benefits for this drug 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 15, 2019 through October 16, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 15, 2019 through October 16, 2019.
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 shopping with your wife when you began to feel dizzy and thought you might pass out. You sat down and an ambulance was called for you. You say that you took additional medication and your heart palpitations began to subside. When the ambulance responders arrived they tested and evaluated your vitals. You say that after a little while your heart felt to be at a normal rate and the EMT's left shortly after that. You state that the Plan should cover the services because you believe it should qualify as emergency care. 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 August 20, 2019. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code 99291) provided to the enrollee on July 6, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the member's date of death was July 5, 2019 and the plan was terminated and not active on the billed date of service of July 6, 2019.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Review of the Medicare Advantage Prescription Drug (Marx) website, the member's date of death was July 5, 2019. The member's plan was terminated and not active on the billed date of service July 6, 2019. Therefore, we decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code 99291) provided to the enrollee on July 6, 2019.