Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.The Plan must follow Medicare rules.The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to the acute hospital with atypical chest pain and congestive heart failure exacerbation on 2/8/20. On 3/10/20 cardiology noted she was walking 50 feet. She was limited by shortness of breath/weakness. She has incisional pain and is on multiple medications for pain. A 3/10/20 surgery note noted sternal wire complication found on 3/1-sternum stable. Left pleural effusion status post thoracentesis on 3/4. Having 8/10 chest pain with breathing deep. On Roxi for pain which seems adequate as she is functional and sleeping at night. Will take time to heal since sternum has broken at the lower sternal wire. On 3/10/20 was standby assist for sit to supine and sit to stand. The enrollee was walking 125 feet with contact guard assistance without an assistive device. The enrollee had fair to good balance. The enrollee needed contact guard assistance for toileting.The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee does not require this onan intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there is no documentation of skilled nursing or rehab needs.
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 physician reviewer found that there are no skilled nursing needs. The enrollee is not receiving IV medications or fluids. There are no unaddressed medical conditions or conditions that require complex monitoring or medication adjustments.
The enrollee is ambulating short distances and performing essential activities of daily living without hands on assistance. There are skilled therapy needs, but they do not need to be provided on a daily basis. The enrollee's condition would not be expected to deteriorate with services provided on a less than daily basis. 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) admission and services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says that the enrollee is noted to be essentially at her baseline level of function, furthermore her cognitive state of function would be expected to impact her restoration potential and may prohibit material improvement.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 that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
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 you will require physical and occupational therapy to return to a higher level of function. The Plan denied your request. The Plan says your potential to tolerate intense therapy is limited.
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 physician reviewer found that your current level of function is using a Hoyer lift for bed-to-chair and bed-to-wheelchair transfers. You are at moderate assist with bed mobility. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional physical and occupational therapy, but do not require this on an intensive rehabilitation facility therapy program level 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: 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 admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee presented to the hospital with fever and shortness of breath. She was treated medically and medical issues are stable. Plans for discharge home with son and in home care were made for 3/2/20. On 3/5/20 she needed maximum assist x 2 with gait belt, sit to stand and is unable to ambulate. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have new enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the
necessary services on 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 admission to a skilled nursing facility (SNF) 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment liability for the acute inpatient rehabilitation services provided on December 31, 2018 to February 1, 2019.
You asked the Plan to adjust the copayment liability. You say that you were admitted from December 31, 2018 to February 1, 2019. You are responsible to pay a $1,375 copayment for five nights. You feel that you should be reimbursed $1000 as four nights of inpatient services were provided in 2019 and should apply to out of pocket expenses for that year, not 2018. The Plan denied your request. The Plan says there is a $275 copayment for each day formally admitted into the hospital for days 1 to 5 for Medicare-covered hospital care. You must pay these amounts until you reach the out-of-pocket maximum. As of the December 31, 2018 you had not met your out of pocket maximum.
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 a $275 copayment for each day, for days 1-5 for Medicare hospital care.
You have been asked to pay a $1,375 copayment for the first five days of inpatient rehabilitation services (275 x 5= $1,375). 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 adjust the copayment liability for the acute inpatient rehabilitation services provided to the enrollee on December 31, 2018 to February 1, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary, as there will be benefit from short term rehab.The Plandenied your request. The Plansaysneeds can 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 you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. Your functional status does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. You do not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter, you do not require the necessary services onan 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 IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 based on the provided medical records the enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility or sub-acute rehabilitation facility. 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea computed tomography (CT) scan of the shoulder (73200).You asked the Plan to pre-approvea CT scan of the shoulder. You say that the service is necessary.The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that CT scansare covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan of the shoulder. Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee has an unstable shoulder prone to dislocate hence the Hill-Sachs defect. CT of the shoulder would be the best procedure of choice to evaluate the surgical options. 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 CT scan of the shoulder have been met.Therefore, we decided that the Plan has to pre-approvea computed tomography (CT) scan of the shoulder (73200).If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the LTACH admission.
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 that the patient is currently undergoing treatment at an acute care hospital (ACH) for endocarditis, a stroke, bilateral pulmonary emboli and renal failure. The enrollee was intubated/ventilated and subsequently received a tracheotomy. She remains on a ventilator and continues to receive antibiotics. It is unclear if/when she will be appropriate for ventilator weaning. As LTACHs and ACHs 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 ACH until such time no acute services are required. The enrollee can 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided July 25, 2019.
You asked the Plan to pay for the dental services. You say that you went to this same provider the previous
year and was reimbursed. You were also told by a plan representative that the claim denied because of being
coded wrong. The Plan denied your request. The Plan says serves rendered by a provider who as opted out of
the Medicare program will not be covered or payable by the plan.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider that
has opted out of the Medicare program. The file shows that this provider entered into a private contract with
you regarding payment. Therefore, we decided that the Plan does not have to pay for the dental services
provided July 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of skilled nursing facility (SNF) care. You say that the
requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the
enrollee does not meet criteria for the requested continuation of SNF care.
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 continuation of skilled nursing
facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer
found the enrollee admitted to the hospital on 1/9/20 due to altered mental status. Found to have elevated brain
natriuretic peptide, congestive heart failure, with left lower lobe infiltrate. She was admitted to SNF from
1/19/20 to 1/30/20 and then re-admitted to acute care from 1/30/20 to 2/12/20 for pneumonia, acute respiratory
distress and hypoxemia. She was noted medically stable for discharge on 2/11/20. The enrollee admitted back
to SNF on 2/12/20 with a last covered date of 3/1/20. In therapy the enrollee needed supervision to dependence
with activities of daily living. The enrollee needed maximum assistance to dependence for mobility and not
ambulating.
This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a
skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a
SNF. The enrollee does not have complex wound care or other SNF level skilled nursing need. This enrollee's
functional status does not require skilled therapy services with the specialized skill, knowledge and judgment
of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment
at a SNF level. The enrollee does not require these skilled nursing or skilled therapy services (or a combination
of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on
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 continuation of skilled nursing facility (SNF) care have not been met.
Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility
(SNF) care.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prodigy Autocode test strips (A4253).
You asked the Plan to pre-approve the non-preferred test strips. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there are no medical records nor certificate of medical necessity provided to show the reason for using this brand of strip.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-preferred test strips have not been met. Specifically, the record does not include any
medical records to determine the medical necessity of the non-preferred brand of test strip. Therefore, we decided that the Plan does not have to pre-approve Prodigy Autocode test strips (A4253).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the standard wheelchair rental provided on September 13,
2019 by an out of network provider.
You asked the Plan to pay for the standard wheelchair rental. You say that the Plan should pay for the
medically necessary service. The Plan denied your request. The Plan says prior authorization was not
requested.
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 has network providers
available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. We
found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does
not have to pay for the standard wheelchair rental provided on September 13, 2019 by an out of network
provider.