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

 We decided that the Plan has to hold you harmless for inpatient hospital services provided on September 13, 2021.  You asked the Plan to hold you harmless for the inpatient hospital admission. You say that you would like reconsideration because you broke your leg in two places and required surgery. The Plan denied your request. The Plan says that the inpatient hospital services were not medically necessary.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  You were referred for the inpatient hospital admission by a contract provider. The file does not show that the Plan provided notice that the inpatient hospital admission would not be covered. Under Medicare rules, this means the inpatient hospital admission is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for inpatient hospital services provided on September 13, 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: 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 for the enrollee to be admitted to a facility to get therapy and rehabilitation. You state the enrollee cannot be sent home in the state they are in. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the enrollee can receive care in another setting and they could review alternate settings if requested such as skilled nursing facility, outpatient setting or home health care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.    Our physician reviewer found the enrollee 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 needing assist for mobility and status unchanged with close to 3 weeks of therapy, 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 is unlikely to make any significant functional improvement in the predicted 7-10 days of IRF stay as evidenced by their lack of progress now and with previous recent SNF admission. IRF admission is not medically necessary. Document does not support the necessity for admission to IRF. While the enrollee will 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 skilled nursing facility (SNF) with intermittent therapies.  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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 4 additional home health skilled nursing visits.  You asked the Plan to pre-approve home health services. You say that home health care continues to be medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  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 pre-approve home health services. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The patient has no evidence of skilled nursing (SN) needs. There is no evidence of complex wound care, new enteral feedings, or other SN need. She has a daughter and assisted living staff that were noted able to help with reminders. She has chronic stable dyspnea and no evidence of pain or infection. Her needs do not require ongoing home health nursing 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy (CPT code 53854), for the enrollee.  You asked the Plan to pay for the service. You say that the enrollee's symptoms are worsening. The Plan denied your request. The Plan says the Medicare rules have not 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 service. Our physician reviewer found the Medicare coverage criteria have not been met. Specifically, International Prostate Symptom Score (IPSS) greater than or equal to 13 was not provided, maximum urinary flow rate (Qmax) of less than or equal to 15 mL/s (voided volume greater than 125 cc) was not provided and the enrollee is not a poor candidate for other surgical interventions for benign prostatic hyperplasia (BPH) due to underlying disease (e.g., cardiac disease, pulmonary disease, etc.), or at high risk of bleeding.  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 service have not been met. Therefore, we decided that the Plan does not have to pay for transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy (CPT code 53854), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of SNF care from November 26, 2021, forward.  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 health plan's denial should be upheld. No records from November 2021 have been submitted for review. Therefore, there is no evidence to show that ongoing services were medically necessary at the time the denial was issued. Scant records from December 2021 have been submitted. While these records may/may not support a need for services at that time, they do not retroactively support the need for services in November.  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 continuation of SNF care from November 26, 2021, forward.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health physical therapy visits.  You asked the Plan to pre-approve home health physical therapy visits. You say that you can do physical therapy on an outpatient basis but that would not be your first choice as you were under the impression the Centers for Medicare & Medicaid Services (CMS) waiver due to Coronavirus was still in effect and if you could do physical therapy at home to decrease your exposure. The Plan denied your request. The Plan says you do not meet medical necessity for home health physical therapy visits.  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 pre-approve home health physical therapy visits. Our physician reviewer found the records do not show that home health skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. You are not home bound. The documentation does not reveal a detailed neuromuscular or gait evaluation indicating deficits that require skilled therapy. You drive, prepares own meals, and ambulates without assistance. You feed, bathe, dress yourself and use the toilet without assistance. You can rise from a chair without using your arms. The documentation is also conflicting stating you have had no falls in the past year and two (2) falls in the past six (6) weeks.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (80307, 83789, G0480) provided on July 12, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that routine urine drug testing is necessary to monitor the use of these prescriptions as a part of the Prescription Drug Monitoring Program. The Plan denied your request. The Plan says you are not a network provider with the Plan. The Plan also says that the services were not referred by a network provider or rendered in an in-network facility, the services were not urgent or emergent, and the services were not approved in advanced.  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. You must obtain authorization from the Plan prior to seeking care from an out-of-network provider.  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 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 drug testing (80307, 83789, G0480) provided on July 12, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance transport (A0428) provided on September 8, 2021.  You asked the Plan to pay for the ground mileage and non-emergent ambulance transport. The Plan denied your request. The Plan says the medical necessity criteria are not met.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 ground mileage and non-emergent ambulance transport. Our reviewer says that the documentation does not support that the ambulance transport on September 8, 2021 was medically reasonable and necessary for the patient.    Our physician reviewer found the documentation does not support that stretcher van was contraindicated for this patient on September 8, 2021. Our reviewer also found that the documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on September 8, 2021.  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 ground mileage and non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance transport (A0428) provided on September 8, 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 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 there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Truxima (rituximab-abbs).  You asked the Plan to pre-approve the Truxima treatments. You say that it is felt that this should be tried. The Plan denied your request. The Plan says the requested drug is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 the Truxima treatments. Our reviewer says that the requested drug is not considered medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of rheumatoid arthritis. The record states that the enrollee has a contraindication to methotrexate, but no primary source medical records are submitted to support this statement. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's specific condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's specific clinical situation as presented. The elements of the coverage criteria are not satisfied.   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 Truxima treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve Truxima (rituximab-abbs).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis tablets.  You asked the Plan to pre-approve the Eliquis tablets. You say that the enrollee has been taking Eliquis since on or before 2019. You also say that changing the enrollee's anticoagulant at this point can affect their health. The Plan denied your request. The Plan says this drug is a non-covered benefit under the enrollee's plan.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablets.   Benefits for Eliquis tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for a clinic visit, and laboratory testing provided by an out-of-network (OON) provided on April 15, 2021.  You asked the Plan to pay for clinic visit and lab tests. You say that you are requesting coverage so that the enrollee can continue care with their established provider. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and authorization was not obtained.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that plans can require enrollees to get care from network providers.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The enrollee's contract with the Plan does not clearly state whether outpatient clinic services and lab services are covered by the Plan's Point of Service (POS) option. The Plan contract does not clearly disclose which services are included in the POS option. When a service is covered by the POS option, no referral is required for service performed by an out-of-network provider.    Therefore, it cannot be determined whether the clinic and lab services performed required prior authorization when performed by an out-of-network provider. Therefore, the Plan has not shown that its decision to deny payment for these services is correct or justified according to Medicare rules or the Plan contract. Therefore, we decided that the Plan has to pay for a clinic visit, and laboratory testing provided by an out-of-network (OON) provided on April 15, 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 incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that the Bene is need of DME supplies due to having a Foley catheter w/leg bag in place and has sensation changes with pain over left leg with a skin hypersensitivity. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: 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 you broke your hip and are not able to do anything on your own. The Plan denied your request. The Plan says you are medically stable and do not meet criteria for IRF care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the patient 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 this patient 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.