Persius/hicric huggingface dataset:
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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Your 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 therapy to walk again.The Plan denied your request. The Plan says the services are not medically necessary.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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on May 31, 2020 with a right hip fracture after a fall. Pain was well controlled as of June 4, 2020. He needs modified assist for transfers, toileting, and taking one step. He needs minimal to maximal assist with bathing and dressing. The enrollee does not require the intensity of services in an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation.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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital June 2, 2020 with high potassium in the blood (hyperkalemia). You have gout and arthritic changes in the hands. You are medically stable and need maximum to total assistance for activities of daily living. You do not have complex medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve urology services with an out of network provider.You asked the Plan to pre-approve the out of network urology services. You say that the in-network provider that the Plan has referred you to is too far away from your house in LA. You say that traveling to this provider will be a great inconvenience to you and your family.The Plan denied your request. The Plan says you are authorized to receive urology office visits with provider.Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers. You've requested coverage for urology services from a non-contract provider. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from your home who can provide urology services. Under Medicare rules, this means that contract providers are accessible to you.Therefore, we decided that the Plan does not have to pre-approve urology services with an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelongterm acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that transfer to an LTACH is medically necessary for the enrollee.The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not 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 reviewer found that based on the medical records provided, the enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee 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. Medicare coverage criteria for transfer to an LTACH are not met.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 perform, 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.You asked the Plan to pre-approve the home health aide services. You say that you would like reconsideration because the home health aide services are medically necessary. The Plan denied your request. The Plan says your request is not medically necessary because the record shows you are requesting custodial services.The Plan must follow Medicare rules. The rules say that custodial care is not covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health aide services have not been met. Specifically, the record indicates that you are requesting custodial care which is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pre-approve home health aide 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 IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for IRF care are not 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 based on the documentation provided, there is no evidence to show that prior to the IRF admission, the enrollee needed IRF care. Since being admitted to the IRF, records indicate that psychiatric issues are limiting the enrollee's ability and or willingness to perform fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Medicare coverage criteria are not met. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.You asked the Plan to pre-approve the referral. You say that this provider ensures that patients with decreased mobility and travel limitations can receive the quality care they need.The Plan denied your request. The Plan says medically necessary care is available in-network.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-approvea referral to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a functional electrical stimulator and associated supplies.
You asked the Plan to pre-approve the functional electrical stimulator and associated supplies. You say that the enrollee suffers from hemiparesis inter ability to walk would be greatly improved with the e-stim therapy. The Plan denied your request. The Plan says the CMS coverage criteria is not met and use of a functional electrical stimulator is unproven for the diagnosis of contractures and gait instability after a hemorrhagic stroke.
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 functional electrical stimulator and associated supplies. Our reviewer says that the requested functional electrical stimulator and associated supplies are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have non-neurological reasons for disuse atrophy such as casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins). The enrollee is not using Neuromuscular Electrical Stimulation (NMES) for walking due to a Spinal Cord Injury (SCI). 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 functional electrical stimulator and associated supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a functional electrical stimulator and associated supplies.
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 the admission. You say that this is medically necessary, as there are wounds that need to be managed in the SNF.The Plan denied your request. The Plan says this is not medically necessary.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 there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the eylea injection services to be provided by an out of network (OON) provider. You asked the Plan to pre-approve the eylea injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided to the enrollee by a network provider.
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 the eylea injection services 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-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.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 services are not medically necessary. Our physician reviewer found the enrollee was seen on May 27, 2020 due to COVID. He had four falls that month and needed minimal assist with using a rolling walker. He needed modified assist for activities of daily living. A home physical therapy visit dated June 3, 2020 states he needs modified assist for bed mobility, transfers, and walking 30 feet. He has no complex needs that require intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections under Medicare Part B for the enrollee.You asked the Plan to pre-approve Botox injections under Medicare Part B. You say that this treatment is medically necessary.The Plan denied your request. The Plan says because the injections are not taken from physician stock and are retrieved from the pharmacy, they cannot be covered under Medicare Part B.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approve Botox injections under Medicare Part B for the enrollee.Benefits for Botox injections 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve the SNF services. You say that you need a SNF level of care because you are very weak. The Plan denied your request. The Plan says you do not meet Medicare criteria for SNF services.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, you received oral medications. You had stable vital signs. Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT) in the acute hospital. You were at a supervision to contact guard/minimal assist level with functional mobility including gait to 25 feet x 2 with a rolling walker. You required varying assist with activities of daily living. Our physician reviewer found that there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. Although there are identifiable skilled therapy service needs, skilled nursing or skilled therapy services (or a combination of these services) is not medically necessary on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis in a skilled nursing facility setting.You do not meet severity of illness or intensity of service criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve12 physical therapy (PT) visits.You asked the Plan to pre-approve12 PT visits. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 12 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional 12 therapy sessions are generally not accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for her condition which appears to be repetitive exercises and the documentation does not reveal objective measures of functional improvement (i.e. range of motion measurements, strength measurements) that indicates that she requires ongoing skilled therapy to make functional improvements. The documentation does not reveal extenuating factors why she requires the ongoing skills of a professional therapist. Services do not only need to be safely and effectively performed by a therapist, or under the supervision of a therapist. The enrollee should be able to transition to an independent home exercise given the quantity of therapy she has received. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 PT visits have not been met.Therefore, we decided that the Plan does not have to pre-approve12 physical therapy (PT) visits.