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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly moderate to maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 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 pay fora Nutri-Pharmaceutical treatment system (97112, 97032, 97016, 96372, J3490, J3420, J3415, J3411) provided November 27, 2019.You asked the Plan to pay fora Nutri-Pharmaceutical treatment system. You say that this service was medically necessary.The Plan denied your request. The Plan says this service is excluded from Medicare coverage.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 pay for a Nutri-Pharmaceutical treatment system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal objective findings of prior electrodiagnostic testing to indicate the patient has a peripheral neuropathy. There is no documentation that the services are being provided by a licensed therapist or chiropractor. The documentation does not support that electrical nerve stimulation was used in conjunction with standard treatments for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases. The Nutri-Pharmaceutical blend is not a proven treatment for this condition and is considered experimental/investigational for this patient's 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 a Nutri-Pharmaceutical treatment system have not been met. Therefore, we decided that the Plan does not have to pay fora Nutri-Pharmaceutical treatment system (97112, 97032, 97016, 96372, J3490, J3420, J3415, J3411) provided November 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional skilled nursing services.
You asked the Plan to pre-approve the additional skilled nursing services. The Plan denied your request. The Plan says the clinical information received for appeal did not establish medical necessity for the requested services. The Plan also says that the number of visits are excessive for the enrollee's subacute condition.
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 additional skilled nursing services. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the additional skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional skilled nursing services.
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 are appealing with records.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.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 enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. While the enrollee may benefit from multiple therapies such as physical and occupational therapy, the documentation does not support that the enrollee's functional status requires an intensive rehabilitation therapy program provided in anIRF.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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the imaging services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the imaging services. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent
to seek out-of-network care. The Plan says there are equally qualified in-network facilities available to you that
can provide the imaging services you need.
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 imaging services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric osteogenesis stimulator.
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says you have not had a previous failed fusion.
The Plan must follow Medicare rules. The rules say that a spinal electrical osteogenesis stimulator is only covered under certain medical indications.
We looked at the file and the Medicare rules. The records provided do not indicate that you have had a failed spinal fusion, the device will follow a multilevel spinal fusion surgery, or that you have had a previously failed spinal fusion at the same site. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an electric osteogenesis stimulator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve these services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a PET scan is covered to determine the initial level of cancer treatment, to identify bone metastases from cancer, and for infection and inflammation. Therefore, we decided that the Plan does have to pre-approve a positron emission tomography (PET) scan.. We looked at the file and Medicare rules. The file shows that the PET scan is being requested for obstructive sleep apnea. This is not a diagnosis for which Medicare covers this service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical insertion of an interspinous spacer device.

You asked the Plan to pre-approve spinal surgery. You say that if this procedure is not approved the enrollee will be forced to choose between continuation of ineffective conservative treatment or proceeding with a significant surgical procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is considered experimental/investigational and unproven for all indications.

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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is not included in clinical practice guidelines and there has not been a robust head-to-head trial with standard therapy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical insertion of an interspinous spacer device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that you need to remain in the facility because you are improving and because of COVID-19. The Plan denied your request. The Plan says the denial of authorization for continued SNF care is correct, because SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from February 19, 2020 to July 15, 2020. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care.
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 meets criteria for admission. The Plan denied your request. The Plan says the enrollee's needs could be met 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. 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 currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from physical and occupational therapy, but the documentation does not support that the patient's functional status requires 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria 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 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 he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long 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-approve an inpatient hospital admission for hip replacement surgery.
You asked the Plan to pre-approve an inpatient admission. You say that the enrollee requires inpatient hospital care based on medical history, comorbidities, and current medical needs. The Plan denied your request. The Plan says there is no evidence of hemodynamic instability that could only be managed in an acute inpatient setting. 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. 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 an inpatient admission. Our physician reviewer found that there is no documentation provided necessitating an inpatient level of care for the elective procedure. The documentation pre-operatively does not meet the threshold for an intensity of services or underlying member hemodynamic instability that could only be managed in the acute inpatient setting. The review indicates that the record does not show that the enrollee's necessary hospital care will span two midnights. 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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission for hip replacement surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture.You asked the Plan to pre-approve the acupuncture. You say that you would like reconsideration because acupuncture has been helping your condition.The Plan denied your request. The Plan says the requested acupuncture service is not a Medicare covered benefit.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, coverage for acupuncture is limited to treatments for CLBP. In your appeal, you state you are requesting acupuncture services to treat hot flashed. This is not a Medicare covered benefit.Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids purchased on October 29, 2019 by an out-of-networkprovider.You asked the Plan to pay forthe hearing aids. You say that you were not told you had to go to another provider.The Plan denied your request. The Plan says you do not have out-of-network benefits.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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.Review of the file show that you purchased the hearing aids on October 29, 2019 by an out-of-networkprovider. Your EOC states, you must use a supplemental hearing aid plan provider to receive this benefit. 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. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe hearing aids purchased on October 29, 2019 by an out-of-network provider.
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 SNF services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records provided do not show that you require daily skilled nursing and/or daily skilled therapy services at an inpatient SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous lumbar decompression procedure.
You asked the Plan to pre-approve the requested services. You say that you need the procedure for back pain. The Plan denied your request. The Plan says you do not meet coverage criteria for the requested service.
The Plan must follow Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar Decompression is only covered under certain medical indications. We looked at the file and Medicare rules. The documentation does not indicate that you are enrolled in an approved clinical study. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous lumbar decompression procedure.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation for the enrollee.
You asked the Plan to provide coverage for additional routine transportation. You say that additional transportation is necessary for the enrollee. The Plan denied your request. The Plan says once this benefit is exhausted it cannot be extended.
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 36 trips per year. The enrollee has exhausted the trips allowed. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation for the enrollee.