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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility.
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 an aortic valve replacement and a post-operative stroke. Medical problems 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.
While the medical record supports a need for physical and/or occupational therapy, there is no documented
need for intensive rehabilitation services. Medically necessary care 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you had two hip replacements and a spinal infusion, and you have been immobile for three weeks and need acute rehabilitation. You say that you can barely walk and the skilled nursing facility does not give you the same level of care and treatment and home outpatient therapy will be insufficient. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.
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 that 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 were admitted for pneumonia. Your 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 IRF admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental implant, custom abutment, and abutment-supported crown for teeth 3 and 4.
You asked the Plan to pre-approve these services. You say that you are in pain and need the services. The Plan denied your request. The Plan says the services are not covered.
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 implants for a single tooth only. We looked at the file and Medicare rules. The file shows that the request is an implant for more than one tooth. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental implant, custom abutment, and abutment-supported crown for teeth 3 and 4.
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 inpatient rehabilitation services are medically necessary for this enrollee. The Plan denied your request. The Plan says criteria for admission to an IRF have not been met; the enrollee's ongoing skilled therapy and nursing needs can be provided 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 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 that, based on the documentation provided, 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 with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-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 LTACH services.
You asked the Plan to pre-approve the LTACH services. 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 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 they are currently receiving care. 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation for a second medical opinion to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON consultation. You say that you want a second opinion on your diagnosis, and you would like to see a medical center that is out-of-network. The Plan denied your request. The Plan says there are other providers in the Plan's network who are able to provide a second opinion.
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 requested second opinion/consultation. We found no exception that would require the Plan to pre-approve these items/services out-of-network. Therefore, we decided that the Plan does not have to pre-approve a consultation for a second medical opinion to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the drug is not being prescribed for a medically accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the review indicates that the use of Prolia in males is limited to a diagnosis of osteopenia in men at high risk of fracture receiving androgen deprivation therapy for non-metastatic prostate cancer or osteoporosis. The documentation does not support that the Prolia is medically reasonable and necessary for the enrollee. The documentation does not support that the Prolia is safe and effective for the enrollee. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 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 are being discharged from the hospital and are needing to get transferred to the rehab side of the hospital. 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 you do not meet Centers for Medicare and Medicaid Services (CMS) criteria for an IRF admission. You are medically stable with no evidence of need for supervision by acute rehab physical medicine and rehabilitation (PMR) physician. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) studies of a lower extremity joint (73721).
You asked the Plan to pre-approve MRIs. You say that this is medically necessary. The Plan denied your request. The Plan says x-rays are required prior to an MRI.
The Plan must follow Medicare rules. Medicare rules say that MRIs are 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 MRIs. Our reviewer says that the requested MRIs are not medically necessary. Our physician reviewer found the record indicates that the enrollee has a history of fibromyalgia and resolved knee pain from 2020. The enrollee now has pain and swelling above both patellas. A physical examination did not show any instability. No plain films have been obtained. There is no evidence of conservative treatment failure or attempts at physical 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 MRIs have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) studies of a lower extremity joint (73721).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement CPAP device (CPT code E0601), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the enrollee's current CPAP machine is only three (3) years old and is currently part of the Phillips recall and you state the enrollee is having problems with the machine turning on by itself. The Plan denied your request. The Plan says replacement and repair are covered only when medically necessary and if it is not covered under a manufacturer's warranty or purchase agreement. The Plan states these criteria are not met because the enrollee's CPAP machine is currently under warranty and therefore under the recall from Phillips. The Plan states the provider has evaluated the enrollee's CPAP
machine and cannot find any mechanical issues above and beyond the recall and state that the enrollee's machine is working properly.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The enrollee's CPAP machine is currently under warranty and therefore under the recall from Phillips. Therefore, we decided that the Plan does not have to pre-approve a replacement CPAP device (CPT code E0601), for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 19, 2021.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for laboratory services provided on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.

You asked the Plan to pre-approve the benefits. You say that this is medically necessary. The Plan denied your request. The Plan says you have none of the qualifying diagnoses.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Plan rules state that there are specific conditions for which special supplemental benefits for the chronically ill. 

The diagnosis of high blood pressure does not qualify for the requested benefit. Based on this information, we decided that the plan rules for coverage of the benefits have not been met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skin debridement (11042) provided April
14, 2020.
You asked the Plan to waive the copayment for the debridement. You say that the service was incorrectly
coded as outpatient surgery. The Plan denied your request. The Plan says the correct copayment was applied.
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 $250
copayment for outpatient surgery services.
You have been asked to pay a $250 copayment for the debridement. The debridement falls within the
outpatient surgery services 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 copayment for a skin
debridement (11042) provided April 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that these should be covered. The Plan denied your request. The Plan says this is not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device provided October 22, 2020.
You asked the Plan to pay for the pneumatic compression device. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this is a noncovered service.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device provided October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.

You asked the Plan to pre-approve the bed. You say that this is needed to meet the enrollee's medical needs. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device and humidifier.
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says it is the manufacturer's responsibility to provide a replacement device for recalled items.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. We looked at the file and the rules. The file shows that the enrollee has a CPAP device and humidifier. The enrollee's current items serve the same purpose as the requested items. The records do not show that the requested items are needed due to loss or irreparable damage. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device and humidifier.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided March 2, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be charged the copayment. The Plan denied your request. The Plan says the correct copayment was applied.
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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the emergency care 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 copayment for an emergency room visit provided March 2, 2021.