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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the 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 acute care on 1/18/20 for non-displaced intertrochanteric fracture of right femur. He is now status post right hip cepahlomedullary nail on 1/19/20. Recent therapy notes from 1/29/20 indicate the member's pain is controlled. The member is hemodynamically and clinically stable. There is contact guard assist/standby assist needed for transfers, and supervised with ambulation (noting some safety concerns) is appreciated. Toilet use is minimal assist per occupational therapy on 1/29/20. 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 minimal/standby assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy can allow for measurable gains to be achieved within a predicted and reasonable period. 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-approvethe surgical insertion of the Superion Interspinous stabilization device (22869).You asked the Plan to pre-approvethis service. You say that the service is medically necessary as the patient hasLumbar Stenosis.The Plan denied your request. The Plan says medical studies haven't proven thatthe device is helpful for the treatment of the enrollee's health problem.Therefore, Medicare nor the Plan provides coverage for this service. 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the Superion Interspinous stabilizationdevice remains experimental as more research is needed. Therefore, this service 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 this service have not been met.Therefore, we decided that the Plan does not have to pre-approvethe surgical insertion of the Superion Interspinous stabilization device (22869).
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 based on the documentation, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrical stimulator supplies (A4595).
You asked the Plan to pre-approve these services. You say that The Plan denied your request. The Plan says that this is not covered.
The Plan must follow Medicare rules. Medicare rules say that claims for code A4595 to be used with code E0762 will be denied as not reasonable and necessary. We looked at 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 electrical stimulator supplies (A4595).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan doesnot have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan saysMedicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that require an IRF level of care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care.Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan doesnot have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the first chemotherapy infusion and injections. We decided that the Plan does not have to pay for the second chemotherapy infusion (96417).
You asked the Plan to pay for the chemotherapy administration and injections. You say that you would like reconsideration based on the record submitted. The Plan says that the documentation submitted does not support the services billed as does not include an infusion start and stop time.
We decided that the Plan has to pay for the first chemotherapy infusion (96413) and injections (96375x3).
The Plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, 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 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 chemotherapy administration and injections. Our reviewer says that the start time, dose and rate of both infusions is noted. Given these numbers, it can be calculated that the first infusion lasted 25 minutes and the second infusion lasted 6 minutes. Our reviewer found the documentation clearly shows that three pre-medications were given via injection, followed by two infusions of chemotherapy agents.
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 first chemotherapy infusion and injections have been met. Therefore, we decided that the Plan has to pay for the first chemotherapy infusion and injections.
We also decided that the Plan does not have to pay for the second chemotherapy infusion (96417).
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 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 second chemotherapy infusion (96417). Our reviewer says that the start time, dose and rate of both infusions is noted. Given these numbers, it can be calculated that the first infusion lasted 25 minutes and the second infusion lasted 6 minutes. Our physician reviewer found infusions lasting less than 15 minutes are to be billed as injections/pushes, not infusions. 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 second chemotherapy infusion (96417). have not been met. Therefore, we decided that the Plan does not have to pay for the second chemotherapy infusion (96417).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral radiofrequency ablation of the sacroiliac joint (64640).

You asked the Plan to pre-approve this service. You say that bilateral radiofrequency ablation of the sacroiliac joint is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of bilateral radiofrequency ablation.

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 bilateral radiofrequency ablation of the sacroiliac joint. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the procedure is considered experimental/investigational due to the wide variation in efficacy in the published literature. Therefore, it is deemed not medically reasonable or 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 bilateral radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral radiofrequency ablation of the sacroiliac joint (64640).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transfer from an IRF to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the transfer. You say that this is medically necessary. The Plan denied your request. The Plan says the services you need can continue to be met at the current IRF.
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 transfer. Our reviewer says that daily skilled services are not necessary. 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. 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 only in a SNF. 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 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 transfer have not been met. Therefore, we decided that the Plan does not have to pre-approve a transfer from an IRF to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided to the enrollee on June 13, 2019.
You asked the Plan to pay for this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The plan follows Medicare rules. Medicare rules say that providers must produce medical records showing why the lab services provided were medically necessary. In this case, no records were provided to show the results of this testing would determine a course of treatment of active illness or disease in the enrollee. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for molecular pathology services provided to the enrollee on June 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued care with the out-of-network provider,"the doctor". You asked the Plan to pre-approvecontinued care with the out-of-network provider. You say that the requested continuation with the out-of-network provider is medically necessary.The Plan denied your request. The Plan says the requested continuation with the out-of-network provider is not medically necessary and the enrollee can safely transition to an in-network oncologist that treats Paget's disease of the vulva.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.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 continued care with the out-of-network provider. Our reviewer says that the requested continuation with the out-of-network provider is not medically necessary and the enrollee can safely transition to an in-network specialist. Our physician reviewer found the enrollee is with a diagnosis of Other specified malignant neoplasm of skin, unspecified. She has been diagnosed with Paget's disease of the vulva. A surgical pathology report dated 8/13/18 documents a diagnosis of Inflammatory dermatosis. The enrollee is being followed for a clinical diagnosis of Paget's disease. The documentation does not support the medical necessity of continuing care with an out-of-network provider. Gynecologic oncologists are available in the enrollee's network. The documentation does not identify anything unique about this enrollee's condition that would make it medically necessary for her to continue care with the out-of-network provider. The documentation supports that the enrollee's medical management and follow-up care can be safely transitioned to an in-network specialist 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 continued care with the out-of-network provider have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued care with the out-of-network provider, "the doctor".
Appeal type: Drugs
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted 1/22/2020 for acute on chronic respiratory failure. The member is noted to have been in and out of the acute hospital and a skilled nursing facility since November 2017 with both cardiac and respiratory issues. The member was found to have acute respiratory failure with a pulse oxygen level of 73% on 2LO2. The member's respiratory status is compromised due to significant kyphosis and a large Morgagni hernia causing right lung atelectasis. The member has been treated with high flow oxygen and IV antibiotics. The member is currently stable but improving. There is no documentation provided necessitating admission to a LTACH. The member requires continued acute level of care services and is receiving appropriate care at the present acute care hospital. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Carboplatin for the enrollee.
You asked the Plan to pre-approve Carboplatin. You say that this should be approved. The Plan denied your
request. The Plan says that that there is no support for carboplatin monotherapy.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Carboplatin. Our reviewer says that
Carboplatin is medically reasonable and necessary for the enrollee in this case. Carboplatin is supported for
adenocarcinoma of unknown primary and this patient's prostate cancer is an adenocarcinoma but there is also
literature to support. Our physician reviewer found that the enrollee's condition meets criteria for coverage of
Carboplatin.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Carboplatin have been met. Therefore, we decided that the Plan has to preapprove
Carboplatin for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the deductible for an eye exam (92004) provided on September 6, 2018.
You asked the Plan to waive the deductible for the eye exam. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this claim processed correctly as you had not met your deductible for 2018.
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 states that your deductible does not apply to specialist services. We looked at your contract with the Plan. The Plan contract clearly states that the deductible does not apply to specialist services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the deductible for an eye exam (92004) provided on September 6, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approveIRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met in an alternate level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the 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 required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does 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-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.