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

We decided that the Plan does not have to pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approveIRF care. You say that this is medically necessary.The Plan denied your request. The Plan says alternate settings should be reviewed, such as skilled nursing facility, outpatient setting, or home health 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 above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Emgality for enrollee.You asked the Plan to pre-approve Emgality. You say that Botox is not working for the enrollee.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.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 Emgality for enrollee.Benefits for Emgality 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for adjacent tissue transfer provided to the enrollee on July 15, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says that the requested service code is not substantiated by the clinical documentation in the medical records submitted for review.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 14301 is "Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm."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 services. Our reviewers says that the services at issue in this case were coded correctly. Our physician reviewer found the documentation supports that the coding of CPT 14301 was appropriate in this case for the rotational flap of a 42 sq cm portion of tissue. The Operative Report dated 7/16/2019 documents the following: "Then skin flaps were elevated. Fasciocutaneous skin flaps were elevated and transposed to take tension off the skin. This was closed in an advancement rotation flap type configuration. Total area of local tissue rearrangement was 7 x 6 cm and the deep dermis was closed with interrupted 3-0 Vicryl followed by staples for the skin. A drain was placed in the deep recess of the wound prior to final closure and secured with a silk suture."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 been met.Therefore, we decided that the Plan has to pay for adjacent tissue transfer provided to the enrollee on July 15, 2019.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) services for the enrollee.You asked the Plan to pre-approve SNF services. You say that the member is not ready to go home.The Plan denied your request. The Plan says that the enrollee does not meet criteria for skilled admission, does not require any daily skilled nursing services, and does not require daily skilled therapy on an inpatient basis.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee does not meet Medicare coverage criteria for SNF 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are no needs that require a coordinated approach of team conferencing involving rehab doctors, rehab nurses, social workers and therapists.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found therecords do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofIRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you would like the Plan to reconsider their denial.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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided from August 6, 2019 to August 8, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you disagree with the charges because you were admitted due to the hospitals error.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $345 copayment per day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from August 6, 2019 to August 8, 2019. Therefore, you are responsible to pay a $345 copayment for days 1-2 (August 6, 2019 to August 7, 2019). $345 (copayment) x 2 (inpatient days) = $690.You have been asked to pay the total copayment amount of $690 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 copayment foran inpatient hospital stay provided from August 6, 2019 to August 8, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Procrit medication (J0885).You asked the Plan to pre-approvethis medication. You say that the medication is medically necessary for the enrollee.The Plan denied your request. The Plan says the requested drug is subject to step therapy. This requirement encourages the enrollee to try the preferred drug Retacrit, which is just as effective. The Plan did not receive documentation supporting the medical necessity for a step therapy exception.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 this medication. Our reviewer says that the enrollee does not meet criteria for coverage of the Procrit medication. Our physician reviewer found the enrolleehas not tried and failed the preferred drug Retacrit. Additionally, the documentation does not support that Retacrit would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says the enrollee does not have an illness complex enough to require further hospital care.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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including oxygen supplementation with nighttime BiPAP, nebulizer treatments, surveillance laboratory studies, intravenous antibiotics, telemetry monitoring, ileostomy care, close fluid balance, wound care with vacuum care, 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 thatthe Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care assistant services.You asked the Plan to pre-approvepersonal care assistant services. You say that the enrollee needs these services to remain in her home.The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. Services for which the sole purpose is to enable the patient to continue residing in their homeand custodial careare not covered.We looked at the file and Medicare rules. The requested home health services are custodial in nature. The record does not show the enrollee has skilled nursing or therapy needs. Based on this information, we decided that Medicare rules for coverage of personal care assistant services have not been met.Therefore, we decided that the Plandoes not have to pre-approvepersonal care assistant services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePromethazine tablets.You asked the Plan to pre-approvePromethazine tablets. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Promethazine tablets are not covered under the enrollee's Medicare Part B benefit.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-approvePromethazine tablets.Benefits for Promethazine tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approve an office visit. You say that you would like to continue to see the same doctor you have used in the past.The Plan denied your request. The Plan says you have been approved to see the in network physician.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 an office visit 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 an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient rehabilitation facility 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 above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient'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 patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional physical and occupational therapy, but the patient does not require this therapy 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 an 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 long term acute care hospital (LTACH) services.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 in the case of this enrollee, admission was related to respiratory related to acute alcohol withdrawal and required BiPAP. Improvement was documented, however, recent findings on pulmonary imaging warranted an additional IV antibiotic. Treatment needs included ongoing pulmonary support with BiPAP, close monitoring withdrawal symptoms, and IV antibiotic treatments and chest imaging all of which warrant ongoing acute care. However, there was no indication these needs would go beyond 25 days, and there were no proposed services at the LTACH that were not already being provided and covered at the current facility. Transfer to a lower level of care would be warranted when more appropriate. Therefore, this request for LTACH services will be considered not medically necessary 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 a Lumbar Microdiscectomy.You asked the Plan to pre-approve a Lumbar Microdiscectomy. You say that the service is needed.The Plan denied your request. The Plan says medical necessity has notbeen established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Lumbar Microdiscectomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria is not met. There is no clear correlation between imaging and exam. The procedure is not needed.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 Lumbar Microdiscectomy have not been met.Therefore, we decided that the Plan does not have to pre-approvea Lumbar Microdiscectomy
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says needs can be safely and effectively met in another setting, such as a SNF.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's medical conditions appear stable. There are no complex wound care needs. She does not require medical oversight of her condition at an acute hospital level of care. The enrollee has a new unilateral lower extremity impairment without identified significant upper extremity impairment and does not require the intensity of an acute level rehabilitation therapy program. The enrollee is limited by pain after her fall and recent surgery. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at an SNF 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for a refractionprovided on November 18, 2019.You asked the Plan to pay for the refraction.The Plan denied your request. The Plan says original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts.The Plan must follow Medicare rules. The rulessay that refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.  We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. The file shows that part of this exam was for a refraction. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction providedon November 18, 2019.