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

We decided that the Plan does not have to pre-approve inpatient mental health treatment.

You asked the Plan to pre-approve inpatient mental health treatment. 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. 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 mental health treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, criteria for continued acute inpatient mental health treatment for the dates in question of February 22, 2021 forward is not met as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment while not showing any threats to the safety of yourself or others. 

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 mental health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mobile x-ray services (Q0092, R0070).

You asked the Plan to pay for the mobile x-ray services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid place of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code Q0092, & R0070 is not supported in the medical record. Specifically, the claim shows Place of Service 31, however the record does not show a qualifying Part A SNF stay. Based on this information, we decided that Medicare rules for coverage of the mobile x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for mobile x-ray services (Q0092, R0070).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient hospital admission.

You asked the Plan to pre-approve an acute inpatient hospital admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated as an outpatient.

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 pre-approve for an acute inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the record shows that the enrollee has undergone previous lumber decompression and fusion. She has no documented medical problems. The enrollee is taking prescription pain medication but is taking no other prescription medications. Given the enrollee's stable medical condition, it is not reasonable for the admitting physician to expect that the enrollee's necessary hospital care will span two midnights in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an acute inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient hospital admission.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.

You asked the Plan to pre-approve home health services. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have been receiving home health nursing services to provide wound care to a diabetic foot ulcer (DFU). The DFU has continually improved and is nearly healed over. The wound care required at this point is not skilled. Arrangements have been made for a caregiver. The documentation does not support that ongoing skilled nursing services are medically necessary or reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS emergency ambulance (A0429) and ground mileage (A0425).

You asked the Plan to pay for the ambulance services. You say that you are requesting reconsideration of the denied claim and reprocess for payment. The Plan denied your request. The Plan says ambulance transportation was not medically necessary.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ambulance services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's presenting symptoms does not meet the prudent layperson criteria for emergency care. The documentation does not support that other means of transport was contraindicated. The enrollee did not require special equipment or services during transport. Therefore, this request for ambulance transport will be considered not medically necessary based on the provided documentation.

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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for BLS emergency ambulance (A0429) and ground mileage (A0425).
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 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 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 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 they are currently receiving care. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter.

You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your
request. The Plan says this has not been proven to be safe or effective.

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 scooter. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the requested knee scooter is not proven safe and effective for your condition. The documentation does
not reveal supportive evidence that you are unable to use crutches for this condition.

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 scooter have not been met. Therefore, we decided that the Plan does not
have to pre-approve a knee scooter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services exceed your benefit 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 Plan covers a maximum of 60 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that once you have used the remaining approved 60 transportation trips, you will 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 trips.
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 it is felt that intensive therapy is required to return the enrollee to baseline. The Plan denied your request. The Plan says the criteria for IRF care are not met in this case.

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 patient's medical status does not require intensive physician or nursing supervision in an IRF. While the patient may benefit and participate in multiple therapies the patient's functional level does not require this on an intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve diabetic shoes (A5500) and inserts (A5514).

You asked the Plan to pre-approve diabetic shoes and inserts. You say that the criteria for coverage are met.
The Plan denied your request. The Plan says that the records do not show that the enrollee has a covered
condition.

The Plan follows Medicare rules. Medicare rules say that therapeutic shoes, inserts and/or modifications to
therapeutic shoes are covered if all of the criteria listed in the LCA are met.

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 diabetic shoes and inserts. Our reviewer
says that the criteria for coverage of the requested items have been met. Our physician reviewer found the
progress notes documented in this medical chart reveal that this patient suffers with type II diabetes with
peripheral neuropathy and evidence of callous formation. The patient is also noted to have a hallux valgus
deformity as well as diminished dorsalis pedis pulses and absent posterior tibial pulses. With these physical
findings, the patient meets the coverage criteria for diabetic shoes and diabetic multi-density insoles.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of diabetic shoes and inserts have been met. Therefore, we decided that the Plan
has to pre-approve diabetic shoes (A5500) and inserts (A5514).

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: 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. The Plan denied your request. The Plan says the enrollee is not stable for transfer.

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 the enrollee presented to the acute hospital with shortness of breath, requiring intubation. he enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically reasonable or 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 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 prostate artery embolization (PAE) for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says this is not clinically appropriate or considered effective.

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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. PAE is currently an experimental treatment for this diagnosis. The American Urological Association BPH clinical guidelines state that PAE should only be performed in the context of an experimental clinical trial 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve prostate artery embolization (PAE) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical epidural steroid injection (ESI).

You asked the Plan to pre-approve the ESI. You say that it is felt that this ESI is necessary. The Plan denied your request. The Plan says the requested service is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that ESIs may be considered reasonable and necessary when certain criteria are met. 

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 ESI. Our reviewer says that the requested ESI does not meet Medicare criteria for medical necessity. Our physician reviewer found the documentation does not demonstrate the presence of a central or systemic process for the cervical pain. No imaging results are recorded. This is a one-time visit without evidence of failure of conservative therapy. The documentation does not correlate the functional deficit to the cervical area and there is no documentation of impingement on imaging studies. 

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 ESI have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical epidural steroid injection (ESI).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nuclear stress test.

You asked the Plan to pre-approve a nuclear stress test. You say that the clinical documentation provided supports the need for a nuclear stress test. You say that the enrollee has upcoming surgery and that the requested test is needed for risk stratification. The Plan denied your request. The Plan says the records do not show that the enrollee is unable to do a treadmill stress test.

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 a nuclear stress test. Our reviewer says that a nuclear stress test is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has increased coronary risk but no chest pain, no documented limited functional capacity and is scheduled for non-high-risk surgery. In this circumstance the records do not support the medical necessity for nuclear stress testing. Specifically, the surgery is not reported to be high risk, there is no documented poor functional capacity and there is no documented other covered indication for the procedure. 

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 nuclear stress test have not been met. Therefore, we decided that the Plan does not have to pre-approve a nuclear stress test.
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 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 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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care due to his medical condition. The Plan denied your request. The Plan says the enrollee does not meet IRF 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 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 patient's medical status does not require intensive physician or nursing supervision in an IRF. While the patient may benefit and participate in multiple therapies the patient's functional level does not require this on an intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.