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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for an IRF are not met. The enrollee's care needs can be met in a less intensive setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that 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 does require physical therapy and occupational therapy services, but based on the provided medical records, the enrollee does not require an intensive inpatient rehabilitation therapy program provided in an IRF. Care can be provided in an alternate 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 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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary and the enrollee's needs cannot be met in a lower level of care. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's care needs can continue to be met in the skilled nursing facility setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from September 21, 2021, onward.

You asked the Plan to pre-approve continued inpatient mental health care. You say that the enrollee is not able to care for himself outside of the hospital and needs to be in a locked and secured facility. The Plan denied your request. The Plan says as of September 20, 2021, the inpatient psychiatric care was no longer medically necessary. The enrollee can be moved to a lower level of care.

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 continued inpatient mental health care. Our reviewer says that based upon a review of the provided records, the enrollee does not meet the criteria for treatment in an acute inpatient mental health facility beyond the date in question of September 21, 2021. Our physician reviewer found that it is not expected that this enrollee will improve in a reasonable period of time beyond the dates in question as they were not showing any dangerousness to self or others, auditory or visual hallucinations, and they were without aggressive behaviors while not showing any acute threats of safety. The enrollee was cooperative and compliant with medication. It does 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. The health plan's denial appears appropriate in this case, and the enrollee can be treated in a less restrictive 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 continued inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from September 21, 2021, onward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303).
You asked the Plan to pre-approve the bed. You say that this is needed because of your medical condition at the moment. The Plan denied your request. The Plan says the weight criteria was not met.
The Plan must follow Medicare rules. Medicare rules say E0303 is covered for enrollees between 350 and 600 pounds. We looked at the file and Medicare rules. You weigh 236 pounds. This is outside of the range for this requested bed. Based on this information, we decided that Medicare rules for coverage of the bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a specialist office visit. You say that you would like to see this specific provider. The Plan denied your request. The Plan says there are in-network physicians available to provide these services.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-network (OON) provider.
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 enrollee needs to be transferred to a
facility that can wean them from the vent. The Plan denied your request. The Plan says the criteria for
admission to an LTACH have not been met. The enrollee's medical needs are being met in the current acute
setting, and the LTACH would add no additional services.

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 enrollee is receiving appropriate acute hospital care, and acute care services have
not been denied by the Plan. 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. 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care and debridement provided
on June 9, 2020 by an out-of-network provider.

You asked the Plan to pay for subsequent nursing facility care (99308) and debridement (11042). You say that
the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior
authorization as required.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for subsequent nursing facility care and debridement provided on
June 9, 2020 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and endodontic therapy to be provided by
an endodontist.

You asked the Plan to pre-approve the consultation and endodontic therapy. You say that due to your financial
situation you are unable to pay for these services out of pocket. The Plan denied your request. The Plan says
services performed by an endodontist are not covered because your Plan's supplemental dental benefits are
limited to services performed by a participating general dentist.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
covered when they are provided by anyone other than a participating general dentist. Therefore, we decided
that the Plan does not have to pre-approve a consultation and endodontic therapy to be provided by an
endodontist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture with a flexible base (D5225) and inhalation of nitrous oxide/analgesia (D9230).
You asked the Plan to pre-approve the denture and analgesia. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture with a flexible base (D5225) and inhalation of nitrous oxide/analgesia (D9230).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin more than three times per day and adjust your insulin based on blood glucose levels.

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 a continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says with additional time in the rehabilitation hospital, the enrollee may be ready to
receive services in another setting, such as an outpatient setting or home.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the
medical records provided there is no documentation that the enrollee requires skilled nursing services. The
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and
effectively provide medically necessary and reasonable treatment. The enrollee does not require these services
on an inpatient basis, only in a skilled nursing facility setting. Continued care in the acute rehabilitation facility
is appropriate until the enrollee is stable to transfer to a lower level of care such as home with home health care
or to a nursing facility with part time 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 the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a screening computed tomography colonography
(CTC).
You asked the Plan to pre-approve these services. You say that the enrollee has a history of colon polyps. The
Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that screening computed tomographic colonography (CTC)
is not covered
We looked at the file and Medicare rules. The services at issue are screening CTC. These services are not
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a screening computed
tomography colonography (CTC).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on January
20, 2021.
You asked the Plan to pay for the testing services. You say that you collect the samples from the enrollee's
home. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician
who is treating the beneficiary.
We looked at the file and the rules. We find that the screening testing is not supported in the medical record. Specifically, the records provided do not show that the physician listed ordered the test or would use the results in the management of a specific medical problem. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on January 20, 2021.
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 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 enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing (CPT code(s): 81404, 81406, 81479) provided to the enrollee on October 20, 2020.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The enrollee had cardiovascular risk assessment testing on October 20, 2020. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing (CPT code(s): 81404, 81406, 81479) provided to the enrollee on October 20, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for application of a modality to 1 or more areas; hot or cold packs (CPT code 97010), application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes (CPT code 97032), and the office visit (CPT code 99212) provided from March 22, 2021, through March 31, 2021.
You asked the Plan to pay for the services. You say that the services should be covered in full after paying your copayment. The Plan denied your request. The Plan says these services are not Medicare covered chiropractic services. 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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for application of a modality to 1 or more areas; hot or cold packs (CPT code 97010), application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes (CPT code 97032), and the office visit (CPT code 99212) provided from March 22, 2021, through March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions to be provided by an oral surgeon.
You asked the Plan to pre-approve the extractions. You say that your general dentist advised you that the extraction required an oral surgeon. You say that you are in pain and need the Plan to approve the request. The Plan denied your request. The Plan says services provided by an oral surgeon are not included in your dental contract.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, services provided by an oral surgeon are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve extractions to be provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient mental health admission.
You asked the Plan to pre-approve the acute inpatient mental health admission. You say that the enrollee has
not been discharged due to the continued need of psychiatric services until stabilized. The Plan denied your
request. The Plan says an acute inpatient mental health admission 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 the acute inpatient mental health
admission. Our reviewer says that the admission of this enrollee does not meet the criteria for acute inpatient
mental health treatment. Our physician reviewer found that it does 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
as the member does not have dangerousness to self or others or perceptual disturbance including auditory or
visual hallucinations. It does not appear that active treatment is taking place. It does not appear that the services
are reasonably expected to improve the member's condition for the purpose of diagnosis.
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 acute inpatient mental health admission have not been met. Therefore, we
decided that the Plan does not have to pre-approve an acute inpatient mental health admission.