Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.You asked the Plan to pre-approve home health care. You say that you are home bound and required home health care.The Plan denied your request. The Plan says home health care is not medically necessary.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 care. Our reviewer says that home health skilled nursing services are not medically necessary at this time. Our physician reviewer found that after review of the medical records, you do not have home health skilled nursing needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met.Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy services to be provided by an out of network (OON) provider. You asked the Plan to pre-approve the out of network proton beam therapy services. You say that , since the
enrollee has undergone a lumpectomy, she is now a candidate for radiation. You say that proton beam radiation can be used to treat left-sided breast cancer with elimination of unnecessary radiation to the underlying heart, lung, and contralateral breast reducing the chances for cardiovascular pulmonary complications, as well as second malignancies. The Plan denied your request. The Plan says there are in network providers who can supply the requested service. 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 provider at issue in this case is not a network provider with the Plan. 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 out of network proton beam therapy 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 the out of network proton beam therapy services have not been met. 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 the out of network proton beam therapy services. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy services to be provided
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

Explanation of decision
We decided that the Plan does not have to pre-approve acute inpatient level of hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient admission is medically
necessary. The Plan denied your request. The Plan says observation level of care is appropriate.
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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this
case. Our physician reviewer found that prior to transfer to the intensive care unit, a decision to use comfort
care suggests there was no clear need for at least a two-midnight stay in the inpatient hospital setting.
Observation care would be most appropriate in this clinical situation, 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 acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient level of hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental services to be performed by an oral surgeon.
You asked the Plan to pre-approve the dental services. You say that you were referred to an oral surgeon by a dentist due to a filling that fell out and the tooth needs to be extracted. The Plan denied your request. The Plan says services must be performed by a participating general dentist.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Your EOC states, services must be performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve the dental services to be performed by an oral surgeon.
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 medical records support the need for IRF care. You say that the enrollee needs daily physician oversight during recovery andmedical monitoring.The Plan denied your request. The Plan says the medical necessity for IRF care has not been established.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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee presented on June 22, 2020 with new-onset seizures. She was started on antiepileptic medication, and has not had ongoing seizure activity. The enrollee has had a prolonged postictal period. The enrollee is currently medically stable, and she does not have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehabilitation physician three times per week. While she may benefit from continuing physical therapy and occupational therapy, there is no evidence of a need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions of teeth #2-14, 17, and 21-27 (D7140).
You asked the Plan to pre-approve extractions of teeth #2-14, 17, and 21-27. You say that the extractions are necessary in order for you to receive your dentures. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria has not been met.
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 Plan covers two non-surgical or surgical extractions per calendar year. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extractions of teeth #2-14, 17, and 21-27 have not been met. The plan covers two non-surgical or surgical extractions per calendar year. The record shows that you had 2 teeth extracted on June 16, 2020. Therefore, we decided that the Plan does not have to pre-approve extractions of teeth #2-14, 17, and 21-27 (D7140).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.
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 were medically stable, with no evidence of a need for supervision by a PMR physician. There is no need for acute rehab nursing care. Functionally, given you are a minimum assist level for mobility, you do not require the IRF level of therapies. You may benefit from further PT and OT, but does not require an intensive therapy program. This admission is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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).
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 home health care. You say that your physician is requesting this home health care. The Plan denied your request. The Plan says the denial of authorization for home health aide services is correct.
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. 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 care. Our reviewer says that you do not meet the Medicare criteria for the requested home health aide services. Our physician reviewer found the requested services do not meet the definition of home health aide services according to Medicare guidelines. Home health aide services are not medically reasonable and necessary for the treatment of your condition by skilled professional staff. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical insertion of an interspinous spacer device (X-Stop procedure). You asked the Plan to pre-approve X-Stop procedure. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve X-Stop procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the X-Stop device is experimental. More research is needed to show the safety and efficacy of this procedure. Also, there is no documented spinal instability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of X-Stop procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve surgical insertion of an interspinous spacer device (X-Stop procedure).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinjections of lower or sacral spine facet joint using imaging guidance (64493, 64494, 64495).You asked the Plan to pre-approveinjections of lower or sacral spine facet joint using imaging guidance. 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 follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain when specific criteria is 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 injections of lower or sacral spine facet joint using imaging guidance. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee wants an approach to therapy that is not in keeping with the standard of care algorithm. The request is 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 injections of lower or sacral spine facet joint using imaging guidance have not been met.Therefore, we decided that the Plan does not have to pre-approveinjections of lower or sacral spine facet joint using imaging guidance (64493, 64494, 64495).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that you feel your needs would be best served in a long term care facility.The Plan denied your request. The Plan says SNF care 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not show that you have identifiable skilled nursing or therapy service needs. 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 coverageof SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda. You asked the Plan to pre-approve the Keytruda. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says there is no evidence in the compendia to support the use of this drug for your condition. The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that the requested drug is not FDA approved for your diagnosis. Our physician reviewer found the requested drug is not supported by one of the major drug compendia or clinical research that appears in CMS-approved medical journals. 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
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 records provided support the need for IRF care.The Plan denied your request. The Plan says the medical records do not support that enrollee's condition meets the guidelines for coverage of IRF care. The Plan says that the care needed could be safely received in another setting.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 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.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 long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from LTACH admission for continued daily monitoring, skilled nursing care, and therapy. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 as LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such time as no acute services are required, then be transferred/discharged to a lower level of care for any ongoing long-term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for replacement catheter services (36581 and 77001) provided on January
6, 2020.
You asked the Plan to pay for the replacement catheter services. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says that payment for this service is
included in the global surgery package for another procedure.
The Plan must follow Medicare rules. Medicare rules say that carriers do not include the services of other
physicians except where the surgeon and the other physician(s) agree on the transfer of care in the global
surgery package.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the replacement catheter services have been met. Specifically, the replacement catheter services
were rendered by a different provider than that which provided the initial surgery. The record does not include
evidence of a transfer of care agreement. Additionally, CPT code 77001 is an appropriate add-on code for CPT
code 36581 and meets criteria for reimbursement consideration. Therefore, we decided that the Plan has to pay
for replacement catheter services (36581 and 77001) provided on January 6, 2020.
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-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says a lower level of care is appropriate.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 condition is generally stable, and he does not have complex medical issues that require acute rehab nursing care or monitoring by an inpatient rehabilitation physician three times per week. While he may well benefit from continuing therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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.