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

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 in the Medicare rules section. 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 was admitted for and epidural hematoma, traumatic brain injury, facial fractures, and a skull fracture after a motorbike accident. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cold therapy unit.
You asked the Plan to pre-approve the requested device. You say that the device is better for the joint. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. A fluid circulating cold pad with pump is not considered reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a cold therapy unit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment),
with any type side rails, with mattress (CPT code E0260).
You asked the Plan to pre-approve DME. You say that the DME is necessary. The Plan denied your request.
The Plan says the Medicare rules have not been 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 durable medical equipment (DME).
Our physician reviewer found the documentation does not clearly reveal how your condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The provider states the debility, congestive heart failure (CHF), and percutaneous endoscopic gastrostomy (PEG) and needs head of the bed up due to medical conditions but these findings are not supported in the history and physical. The request for a semi-electric hospital bed is not medically necessary for you. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress (CPT code E0260).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four additional services performed by a qualified physical therapist (G0151 x4) and nine additional direct skilled nursing services of a RN (G0299 x9).
You asked the Plan to pre-approve the additional services performed by a qualified physical therapist and additional direct skilled nursing services of a RN. The Plan denied your request. The Plan says there is no documentation to support the continuation of physical therapy or skilled nursing services.
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 the additional services performed by a qualified physical therapist and additional direct skilled nursing services of a RN. Our reviewer says that these services are not currently medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented skilled nursing needs. Our reviewer found that the enrollee does not have documented skilled therapy needs. Our physician reviewer also found that the enrollee's care needs at this point are custodial. 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 additional services performed by a qualified physical therapist and additional direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve four additional services performed by a qualified physical therapist (G0151 x4) and nine additional direct skilled nursing services of a RN (G0299 x9).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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. The requested provider in this case is not a network provider with the Plan. 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 for the office visit provided on July 10, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the nebulizer administration set and the nebulizer with compressor provided on February 16, 2021 and February 28, 2021.
You asked the Plan to waive the coinsurance for the nebulizer administration set and the nebulizer with compressor. You say that these claims are COVID-related and should not have a cost share. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for medical supplies from an out-of-network medical supply provider and 18% coinsurance for durable medical equipment from an out-of-network durable medical equipment provider. You have been asked to pay $0.80 which is 20% of the allowed amount for the nebulizer administration set. The allowed amount is $4.42. ($4.42 x 20% = $0.80). You have also been asked to pay 18% of the allowed amount for the nebulizer with compressor. The allowed amount is $9.39. ($9.39 x 18% = $1.69). The nebulizer administration set falls within the "Outpatient diagnostic test and therapeutic services and supplies" benefit category. The nebulizer with compressor falls within the "Durable medical equipment (DME) and related supplies" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the nebulizer administration set and the nebulizer with compressor provided on February 16, 2021 and February 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral radiofrequency thermocoagulation of the medical branch (CPT code(s): 64635 x 2, 64636 x 2, 77003 x 2, and J1040 x 2), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says it appears that the facet joint injection only provided 70% relief twice and only for one (1) week; therefore, the criteria of 80% relief is not 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 services. Our physician reviewer found the enrollee has lumbar radiculopathy and has undergone laminectomy. The enrollee currently has post laminectomy syndrome. The record indicates that the enrollee underwent bilateral facet injections with 70%
one-week improvement in May 2021. A similar result was obtained with a diagnostic injection in 2020. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral radiofrequency thermocoagulation of the medical branch (CPT code(s): 64635 x 2, 64636 x 2, 77003 x 2, and J1040 x 2), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for abutment supported crowns (D6058) provided on June 15, 2020.
You asked the Plan to pay for abutment supported crowns. You say that these services were necessary, and you should be reimbursed for them. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for abutment supported crowns (D6058) provided on June 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive the care needed 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 in the Medicare rules section. 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
was admitted for surgical treatment of a hip fracture after a fall and was transferred to skilled nursing on June 2, 2021, where physical and occupational therapy services are being provided. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve Intracept. You say that you have tried and failed conservative treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Intracept is experimental/investigational.
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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term, peer-reviewed literature that shows this procedure to be a safe and effective treatment for your condition. There is no compelling rationale presented or extenuating circumstance noted to support the medical necessity of Intracept as an exception to guidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care for arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft (CPT code 27130), for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay is necessary. The Plan denied your request. The Plan says the stay is not necessary.
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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is deconditioned due to polio. The provided medical record indicates that the physician anticipates a one to two day stay. The enrollee may be placed in observation status and if needed converted to an inpatient admission if further care is required. The elements of the coverage determination are not satisfied. The requested service cannot be recommended. 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 pay for the acute inpatient hospital care for arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft (CPT code 27130), for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy session (90837) provided on
October 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that you rendered treatment in good faith that
the service will get reimbursed. The service was provided with no adequate time frame to obtain authorization
for the service. The Plan denied your request. The Plan says enrollee's must receive their medical services from
an in-network provider with the exception being urgent or emergent services. Non-emergent services with noncontracted
providers require prior authorization before services being rendered.
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. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 for the individual psychotherapy session (90837) provided on October 22, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is 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 in the Medicare rules section.
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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical
history of a remote stroke, hypertension, and anxiety and is living at home with progressive weakness. Medical
conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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 IRF admission and services.
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 care. You say that the enrollee is at risk of infection if not properly care for. You say that the enrollee needs care that cannot be provided at home and assistance with daily living tasks. The Plan denied your request. The Plan says they did not receive necessary information to support that daily skilled services can only be provided on an inpatient basis in a SNF. The Plan says that the enrollee can safely receive the services needed in the current hospital setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral nutrition and medications, had stable vital signs, and used nocturnal BiPAP. Tracheostomy was being considered and the enrollee required frequent suctioning. The enrollee required wound care to her sacrum and continued to receive blood transfusions. The enrollee was noted to have functional quadriplegia. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.