Persius/hicric huggingface dataset:
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 the stay is medically necessary. The Plan denied your request. The Plan says the enrollee's records show the enrollee would benefit from continued physical and occupational therapy. The Plan states the enrollee's records support that their rehabilitation needs do not require an intensive team for the enrollee to reach their functional goals. The Plan states the records received do not support that they require an intensive therapy program with multiple visits from a rehabilitation doctor per week or that they are able to actively participate in and benefit from intensive therapy fifteen (15) hours per week or that they will improve a lot in a reasonable amount of time. The Plan states the enrollee can safely receive the services they need in other settings, for example: a skilled nursing facility or home with home health and home physical therapy when they are able to transition from the acute care hospital.
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 available records the enrollee with debility form acute illness is medically stable and does not meet Centers for Medicare & Medicaid Services (CMS) coverage criteria for an IRF admission. With the enrollee's current medical stability, and no other medical complexity, there is no need for Physical Medicine and Rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee has no acute rehabilitation nursing needs. At the current functional level, the enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. The enrollee's rehabilitation needs can be addressed just as well in a skilled nursing facility (SNF). IRF admission is not medically necessary based on functional level and lack of medical complexity. Document does not support the necessity for admission to IRF. While the enrollee may benefit from continued physical therapy (PT), and occupational therapy (OT), the enrollee's rehabilitation needs can be safely met in an alternate and low intensity setting such as in a SNF. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. 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 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have
documented skilled therapy needs. Daily skilled services are not shown to be required to establish a
maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are
custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 24, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says due to the enrollee's hospice status on the date of service, this claim must submit to
Original Medicare first for review and then to the Plan.
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 physician services provided to the enrollee on May 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says your request does not show you have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. The Plan states the services you require can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are ambulating household distances and mobilizing with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided May 1, 2021 to May 18, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that the facility did not advise that the cost share would begin after day 20. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $0 copayment for each day for days 1-20 and $184 copayment each day for days 21-100 per benefit period for Skilled nursing facility (SNF) care. You have been asked to pay $920 ($184 x 5 days) for the SNF services. The SNF services falls within the Skilled nursing facility (SNF) 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 the skilled nursing facility (SNF) services provided May 1, 2021 to May 18, 2021.
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 LTACH care is medically reasonable and necessary. The Plan denied your request. The Plan says rules for LTACH care have 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 that the patient is a 70-year-old female who was admitted to the acute care hospital with recent treatment for sepsis, acute renal failure, left inguinal abscess, and associated acute respiratory failure requiring multiple abdominal surgeries complicated by bowel perforation recently declining with hypotension and inability to urinate requiring vasopressors, dialysis, amiodarone drip for atrial fibrillation, antibiotics for pancolitis. She declined colectomy. She is requiring total parenteral nutrition but plans for percutaneous endoscopic gastrostomy is noted. The patient appears to be improving but still unstable for transfer at this time and should only require short-term additional acute care services that can be safely administered at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Transfer to LTACH is not supported or medically necessary due to it not being clinically advantageous. Transfer may be considered when treatment has completed and the patient is more stable. 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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after November
18, 2021.
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that that you have reached maximal improvement and no further SNF stay
is warranted.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before
the last covered day. This notice must include a description of the enrollee's right to an appeal.
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or
more days before November 18, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit
is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the
Plan has to pre-approve continued skilled nursing facility (SNF) services after November 18, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a detachable shower head.
You asked the Plan to pre-approve a detachable shower head. You say that a detachable shower head is medically necessary as you cannot stand for long periods of time. The Plan denied your request. The Plan says a detachable shower head is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower equipment is not covered. While a detachable shower head may be appropriate for your use, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a detachable shower head
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 enrollee is not getting the needed care and ability
to regain her mobility. You say that the enrollee needs more care than what is standard at the current facility.
The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that
the enrollee can safely receive the services needed 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 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 surgical repair of a hip fracture after a fall. The enrollee's 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for
an intensive rehabilitation 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: 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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. The Plan states the enrollee's care can be provided in the current inpatient hospital and they may be ready to move to another setting in the future.
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 was admitted following a stroke and remains intubated. The record indicates that the enrollee requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hereditary hemochromatosis mutation analysis.
You asked the Plan to pre-approve hereditary hemochromatosis mutation analysis. You say that the requested
genetic testing is medically necessary for further evaluation and to rule out other conditions associated with the
iron overload. The Plan denied your request. The Plan says the Medicare criteria for coverage have not been
met.
The Plan follows Medicare rules. Medicare rules say that molecular pathology procedures are covered for
certain clinical indications.
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 hereditary hemochromatosis mutation
analysis. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the
enrollee has abnormal findings of blood chemistry. There is a known family history of hereditary
hemochromatosis. On July 14, 2021, the enrollee was noted to have an elevated serum ferritin of 407. Serum
iron/TIBC/iron sats were not available. No abnormal liver function tests were noted. The plan on December 7,
2021, was to perform detailed iron studies including serum iron, TIBC, percent sats, and repeat serum ferritin.
The case file does not contain the results of the enrollee's iron studies and the transferrin saturation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of hereditary hemochromatosis mutation analysis have not been met. Therefore,
we decided that the Plan does not have to pre-approve hereditary hemochromatosis mutation analysis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.
You asked the Plan to pre-approve a seat lift mechanism. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item have not been met.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are 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 pre-approve a seat lift mechanism. Our reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation that the enrollee is completely incapable of standing from a chair in the home.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
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 stay is medically necessary. The Plan
denied your request. The Plan says there are no required medical services in the LTACH that the enrollee is not
already receiving in their current approved hospital setting. The Plan states as acute care hospitals and LTACH
are licensed to provide the same level of care, there is no advantage in moving the enrollee from the current
acute care hospital to an LTACH.
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 appears to be unstable and has not yet shown that the enrollee is a good
candidate for ventilation support weaning. Completion of short-term additional acute care services that can be
safely administered at the current facility is recommended. The enrollee does not require services at the
LTACH that are not already available at the current facility. There are no services at the LTACH that the
enrollee requires that are not already available and covered at the current facility. Transfer to LTACH is not
supported or medically necessary due to it not being clinically advantageous. Transfer may be considered when
treatment has completed and the enrollee is more stable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a panoramic radiographic image (D0330), and a tooth extraction (D7210) provided by an out-of-network provider on January 8, 2021.
You asked the Plan to pay for a limited oral evaluation, a panoramic radiographic image, and a tooth extraction. You say that you would like the Plan to pay for the remainder of this bill. The Plan denied your request. The Plan says the correct charges have been applied.
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 a limited oral evaluation, a panoramic radiographic image, and a tooth extraction when the services are provided by an out-of-network provider. You might be billed for charges above what the Plan pays, even for services listed as $0 copayment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, a panoramic radiographic image, and a tooth extraction have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), a panoramic radiographic image (D0330), and a tooth extraction (D7210) provided by an out-of-network provider on January 8, 2021.