Persius/hicric huggingface dataset:
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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving appropriate care in the hospital and there is no advantage in transferring to an LTACH at this time. The enrollee can stay until they are safe for transfer or discharge.  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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an in-network exception for physical therapy services to be performed by an out-of-network provider.  You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The Plan denied your request. The Plan says you have access to multiple in-network physical therapist within 1.5 miles of assisted living facility.  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 an in-network exception for physical therapy services to be performed by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve pneumatic compression device. You say that the ordering physician only wants the device supplied by this provider. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this provider is out-of-network with the Plan and this item can be obtained from an in-network equipment supplier.  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 pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Promethazine 12.5 mg tablet.  You asked the Plan to pre-approve Promethazine. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not among the oral antiemetic drugs eligible for coverage under the enrollee's medical benefit.    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 as this drug will not be used in relation to chemotherapy. Therefore, we decided that the Plan does not have to pre-approve Promethazine 12.5 mg tablet.   Benefits for Promethazine 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prednisone 10 mg tablet.  You asked the Plan to pre-approve Prednisone. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  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 Prednisone 10 mg tablet.   Benefits for Prednisone 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis tablet 5mg  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.  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 tablet 5mg
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 would benefit from daily close medical supervision at an IRF. The Plan denied your request. The Plan says under Medicare, the requested IRF care is not medically necessary.  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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 16, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve push handles (K0108).  You asked the Plan to pre-approve push handles. You say that these push handles, separate from what comes with the power wheelchair, are medically necessary. The Plan denied your request. The Plan says there is in no evidence that these unbundled handles would be medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file and Medicare rules. In this case, the requested separate handles from the ones that accompany the power wheelchair would exceed the patient's need in this case. Based on this information, we decided that Medicare rules for coverage of push handles have not been met. Therefore, we decided that the Plan does not have to pre-approve push handles (K0108).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Budesonide 3 mg capsule.  You asked the Plan to pre-approve Budesonide. You say that the requested drug is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  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 Budesonide 3 mg capsule.   Benefits for Budesonide 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an exercise bike.  You asked the Plan to pre-approve the exercise bike. You say that you are requesting continuing your Coronavirus recovery therapy through at home exercise and conditioning which requires the requested durable medical equipment (DME). The Plan denied your request. The Plan says Medicare guideline because an electric tricycle is primarily used for a nonmedical purpose and does not meet the definition of DME.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an exercise bike.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve Intracept. You say that given the physical examination and radiological findings, Intracept is medically necessary and supported. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Intracept procedure is unproven and there is insufficient evidence of efficacy.  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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the chest x-rays you had at an outpatient hospital facility on August 23, 2021, and September 22, 2021.  You asked the Plan to waive the copayments for the chest x-rays. You say that you believe the copayments should be waived because you had these x-rays within 90 days of your surgery.  You said that the cost of these x-rays should be part of the surgery. The Plan denied your request. The Plan says you were charged these copayments correctly.  The Plan says that because the allowed amount for each of these x-rays ($189.31) is less than your copayment obligation, you are responsible for the full allowed amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $195 copayment for x-rays in an outpatient hospital setting.   You have been asked to pay a $195 copayment for each of the chest x-rays. Medicare rules explicitly state that diagnostic radiological tests (like x-rays) are excluded from the global surgical package and are always separately charged. 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 copayments for the chest x-rays you had at an outpatient hospital facility on August 23, 2021, and September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650).  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that implantation of a neurostimulator can be covered if Medicare criteria 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. You are noted to have a history of chronic pain. Coverage of a spinal cord stimulator (SCS) has been requested. According to current guidelines a SCS can be covered as a therapy of last resort. Records provided for review indicated that both your pain management provider and primary care physician recommended weight loss to see if that would ameliorate your pain. However, you never followed up on the recommended consultations/evaluations. As you have not exhausted all other possible interventions in this context, the requested service cannot be determined to meet the requirements for coverage. Our physician reviewer found that your condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650).
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 requires inpatient rehabilitation services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can receive the necessary services in a lower 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 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 acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee's needs cannot be met by home health or skilled nursing. The Plan denied your request. The Plan says it is not reasonable to expect the enrollee to participate in and benefit from daily intensive therapies.  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 physician reviewer found that the enrollee was admitted to the acute care hospital for respiratory failure, sepsis, and pneumonia. His medical problems are stable.   The enrollee does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis.  You asked the Plan to pre-approve Eliquis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.  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.   Benefits for Eliquis 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that an LTACH will give the enrollee the best opportunity to recover. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which an LTACH may offer a therapeutic advantage.  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 there is no documentation provided indicating medical necessity for admission to a LTACH.     The enrollee is receiving appropriate care at the present acute care hospital. 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 LTACH services.