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

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from July 17, 2020 and forward.You asked the Plan to pre-approve continuation of inpatient mental health care. You say that the continuation of inpatient mental health care from July 17, 2020 and forward is medically necessary. The Plan denied your request. The Plan says the continuation of inpatient mental health care from July 17, 2020 and forward is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continuation of inpatient mental health care. Our reviewer says that the continuation of inpatient mental health care from July 17, 2020 and forward is not medically necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospital on July 12, 2020 with Schizoaffective Disorder Bipolar Type. Based upon review of the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no abnormal behaviors. This enrollee was compliant with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. I am unable to find an individualized treatment however the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health hospital beyond the date in question of July 17, 2020 and forward and could be treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care from July 17, 2020 and forward.
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 for the enrollee. You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 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. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. In this case, the member is mostly moderate assist for functional transfers and activities of daily living 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 21, 2020 by a
non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-network provider without prior authorization.
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 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 laboratory services provided on February 21,
2020 by a non-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care.The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of IRF care. The Plan says that the enrollee's needs can be safely received in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care. Functionally, given her current level, the enrollee does not require IRF level of therapies. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability.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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on February 27, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that you were under the impression that colonoscopies are covered in full. You say you were not told there would be a copayment if this were billed as a diagnostic colonoscopy. The Plan denied your request. The Plan says you have been charged 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 a $400 copayment for an outpatient hospital facility. You have been asked to pay a $400 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including service provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows the colonoscopy was indicated because of iron deficiency anemia with chronic diarrhea which makes the colonoscopy diagnostic in nature.
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 the colonoscopy provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for provider visit. You say that this service was provided in the absence of an available in-network provider. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 for the medical services provided on January 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray exam of the lumbar spine (72100) provided on April 23, 2019.You asked the Plan to pay forthe x-ray exam of the lumbar spine. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's contractual policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe x-ray exam of the lumbar spine (72100) provided on April 23, 2019.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is with a past medical history of hypertension and atrial fibrillation who presented to the acute hospital on 07/11/2020 with an intertrochanteric fracture of the right femur after a fall in her home. She underwent surgical repair of the fracture on 07/12/2020. She had some post-operative anemia and was transfused packed red blood cells. She is weak and unsteady and is working with physical and occupational therapy. She is walking up to 12 feet with a front wheeled walker with moderate assistance and is moderate assist for transfers and moderate to maximum assist for most activities of daily living. She is medically stable. Based on the medical records provided 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 enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee is noted to have left knee
pain due to osteoarthritis, for which she has received multiple prior injections. She had a Zilretta injection on
January 10, 2020. The request is for a second Zilretta injection. The safety and efficacy of a repeat Zilretta
injection is not demonstrated; therefore, the injection is not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for allergen immunotherapy services (95117)
provided on March 5, 2020.
You asked the Plan to waive the copayment for the allergen immunotherapy services. You say that you would
like reconsideration because you were told there would not be a copayment for these services. The Plan denied
your request. The Plan says there is a $20 copayment per visit to a specialist.
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 $20
copayment for Specialist services.
You have been asked to pay $10.36 for the allergen immunotherapy services. The allowed amount for these
services is $10.36. The allergen immunotherapy falls within the Specialist services benefit category. This
means that you have been asked to pay the lesser 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 allergen immunotherapy services (95117) provided on
March 5, 2020.
Your complaint about being provided with incorrect cost sharing information by a representative is not a valid
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan.
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a touchscreen remote or upgraded electronics.
You asked the Plan to pre-approve the power wheelchair touchscreen remote, Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that you need Plan denied your request. The Plan says the touchscreen remote is not primarily medical in nature and the upgraded electronics are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. Documentation shows that you have 5/5 strength in the left upper limb. Upper limb strength is adequate for you to be able to control the power options using their own switches which are included in the allowance of these power options. The evaluation shows you are able to drive the power wheelchair therefore, a touchscreen remote is not necessary. Based on this information, we decided that Medicare rules for coverage of the power wheelchair touchscreen remote, Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) have not been met. Therefore, we decided that the Plan does not have to pre-approve a touchscreen remote or upgraded electronics.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home skilled nurse visits for medication management.
You asked the Plan to pay for the home health services. You say that you would like reconsideration because it
will be medically necessary for you to have skilled nursing services after your surgery. The Plan denied your
request. The Plan says the notes do not show that you continue to have a medical problem that needs special
care that only a skilled person can do.
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 pay for the home health services. Our reviewer says
that the records do not show that skilled nursing services are required to effectively provide treatment, care,
and/or services in order to improve your condition, to establish/perform a maintenance program to maintain
your condition and/or prevent deterioration. Our physician reviewer found The documentation does not reveal
complex wound care or other current skilled nursing needs, therefore this request is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan
does not have to pay for home skilled nurse visits for medication management.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cologuard colon cancer screening test.You asked the Plan to pre-approve Cologuard colon cancer screening test. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet criteria for the requested testing.The Plan must follow Medicare rules. Medicare rules say that Cologuard is only covered for enrollees at average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn's Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).We looked at the file and Medicare rules. Review of the file shows that you previously have had a tubular adenomatous polyp. Cologuard is only covered for enrollees who care at average riskof developing colorectal cancer, meaning no personal history of adenomatous polyps. Based on this information, we decided that Medicare rules for coverage of Cologuard colon cancer screening test have not been met.Therefore, we decided that the Plan doesnot have to pre-approveCologuard colon cancer screening test.