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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you are at
baseline.
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 physician reviewer
found that you have acute uncomplicated diverticulitis of the large intestine without perforation or abscess
without bleeding. You do not require skilled nursing services to safely and effectively provide medically
necessary and reasonable treatment. Although you do require skilled therapy services, you do not require the
services on a daily basis. You do not require the necessary services on an inpatient basis in a SNF setting.
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) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional mileage for routine transportation. You asked the Plan to pre-approveadditional miles. You say that all the rheumatologists are over 50 miles away.The Plan denied your request. The Plan says the request exceeds the mileage limit. 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 file shows that transportation over 50 miles was requested. We looked at your request, the records in the case file, and the rules. Your plan only covers transportation for up to 50 miles.We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from your home who can providerheumatology services. Under Medicare rules, this means that contract providers are accessible to you.Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional mileage for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction services (92015) provided January 30, 2020.
You asked the Plan to pay for the vision services. You say that you were involved in an auto accident 12/20/2019. You did not go to the doctor until you felt you could give proper answers to the tests. You were referred to this provider as a new patient. The Plan denied your request. The Plan says this service is not covered unless rendered as a part of a routine eye exam.
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. The health plan contract specifically says coverage for eye refraction during a routine eye exam and when performed by an participating provider. 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 pay for refraction services (92015) provided January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forendodontic therapy (D3310) provided on January23, 2020.You asked the Plan to pay forendodontic therapy. You say that your dentist insisted that this was proper treatment to save your tooth.The Plan denied your request. The Plan says the service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forendodontic therapy (D3310) provided on January 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on January 20, 2020.  You asked the Plan to pay forthe ambulance services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says Original Medicare is responsible for this claim.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on January 8, 2020. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on January 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided March 5, 2019 through April 5, 2019.You asked the Plan to waive the copayment for the SNF services. You say that the facility advised you that they would notify you when you had reached the end of the first 20 days. You were discharged on a Friday thinking it was enough time The Plan denied your request. The Plan says the claim processed correctly per the plan benefits.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 $0 per day for days 1-20 and $172 per day for days 21-100. for skilled nursing facility (SNF) care. You have been asked to pay $1,892. You were changed $0 per day for days 1-20 (March 5, 2019 -March 25, 2019) and $172 per day for days 21-31 (March 11, 2019 -April 5, 2019). The SNF services falls within the skilled nursing facility (SNF) 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 for the skilled nursing facility (SNF) services provided March 5, 2019 through April 5, 2019.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that ongoing skilled services 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 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. 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 patient does require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 21, 2020.
You asked the Plan to pay for the ambulance services. You say that the ambulance service was medically necessary. The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of 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 looked at the file and Medicare rules. The record shows the enrollee, complaining of bouts of dizziness and weakness for a week, was ambulatory, conscious, stable, in no acute respiratory or cardiac distress and had no sign of injury, stroke, or hemorrhage. Neither oxygen nor emergency treatment was needed for transport. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6533.You asked the Plan to pre-approvethe compression stockings. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 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-approvecompression stockings identified with code A6533.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says the clinical information indicates that rehab and medical needs can be safely met in a lower level of care with part-time skilled services in the community, such as in an assisted living facility or long-term care facility with part-time skilled sevices, if ordered by the doctor.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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found no required skilled nursing services are identified.The enrollee does not require therapy daily. As a practical matter, the enrollee does not require these services on an inpatient basis, in a skilled nursing facility setting.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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Venclexta.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says self-administered drugs are not covered.
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 Venclexta.
Benefits for these services 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 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 has a history of stroke and pulmonary emboli, and was admitted to the acute care hospital with an
acute intraventricular hemorrhage. A burr hole was placed, and an external ventricular drain was inserted. A PT
note on 7/27/20 documents that the enrollee was opening her eyes for short periods of time during PROM.
Speech language pathology notes that the enrollee was minimally alert. The enrollee was to remain NPO.
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. The member
is receiving acute hospital care, and acute care services have not been denied. 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 she is currently receiving care. The clinical assessment in the case file does not support that the
enrollee is reasonably expected to benefit from, and improve with, LTACH services. 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: Imaging
Decision: Unfavorable

We decided that the Plan has to pre-approve a lumbar spine MRI and cervical spine MRI.You asked the Plan to pre-approve a lumbar spine MRI and cervical spine MRI. You say that the requested lumbar spine MRI and cervical spine MRI are medically necessary.The Plan denied your request. The Plan says that the requested lumbar spine MRI and cervical spine MRI are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a lumbar spine MRI and cervical spine MRI. Our reviewer says that the requested lumbar spine MRI and cervical spine MRI are medically necessary. Our physician reviewer found this enrollee presents with complaints of persistent severe low back pain with worsening right lower extremity radiculopathy over the past 6 months. She also had severe cervical spine surgery, worsening since surgery. She was status post multilevel lumbar fusion surgery on 3/6/18 and anterior cervical fusion on 4/22/19. Pain prevented her from sleeping, walking more than a few blocks, and bending. She reported right lower extremity numbness and tingling. Physical exam findings were limited due to Covid-19. She had failed to improve with 3 months of physical therapy and daily home exercise program. Under consideration is a request for lumbar spine MRI and cervical spine MRI. Current evidence based medical guidelines and literature would support this imaging request based on failure of over 3 months of conservative treatment, progressive neurologic signs/symptoms, history of prior cervical and lumbar spine surgery, andpotential candidacy for invasive interventions. Therefore, this request for lumbar spine MRI and cervical spine MRI would 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 a lumbar spine MRI and cervical spine MRI have been met.Therefore, we decided that the Plan has to pre-approvea lumbar spine MRI and cervical spine MRI.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the pulp vitality tests (D0460), limited oral evaluation (D0140) and intraoral x-ray (D0220) provided on January 7, 2020.You asked the Plan to pay more for the pulp vitality tests (D0460), limited oral evaluation (D0140) and intraoral x-ray (D0220). You say that per your policy you are covered for diagnostic services up to $1,000. You say that you are uncertain why only $44 was covered.The Plan denied your request. The Plan says the claim processed correctly.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 Plan is only obligated to pay the maximum allowable charge for covered benefits. Therefore, we decided that the Plan does not have to pay more forthe pulp vitality tests (D0460), limited oral evaluation (D0140) and intraoral x-ray (D0220) provided on January 7, 2020.
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 you require this level of care as you are not yet able to care for yourself. The Plan denied your request. The Plan says the records show you are relatively high-functioning and do not require acute hospital care or an intensive rehab program.
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 is a 77-year-old male with a past medical history of diabetes, hypertension and neuropathy who presented to the acute hospital on 07/24/2020 with a fall, slurred speech and L facial droop. His magnetic resonance brain scan showed an acute stroke (hemi-pontine lacunar infarct). He was treated in the hospital with anti-platelet medication and a statin. He is weak and unsteady and is working with physical and occupational therapy. He is walking 130 feet x 2 with a walker with stand-by assistance and is stand-by assist to minimum assist for transfers and activities of daily living. He is medically stable. Transfer to an acute inpatient rehabilitation facility is requested. Based on the medical records provided, 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 patient does require physical therapy and occupational therapy services but does not require an intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully participate in and benefit from 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Lidocaine 5% patch for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medically necessary for the enrollee.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-approvethe Lidocaine 5% patch for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.