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 stay is not medically necessary based on IRF criteria. The Plan states physical therapy at a skilled nursing facility may be covered if requested.  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 on review of the available records the enrollee with debility from acute illness, is medically stable with no complications. With the enrollee's comorbid conditions being stable, they do not need 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. No acute or complex rehabilitation nursing needs noted in the record. At the current functional level with decrease activity tolerance, they are not expected to make a significant functional recovery in a reasonable period of time in an IRF. The enrollee does not need 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. IRF admission is not medically necessary based on lack of medical complexity, and rehab nursing needs. Document does not support the necessity for admission to an IRF. While the enrollee may benefit from physical therapy (PT), occupational therapy (OT) and speech therapies, the enrollee's rehabilitation needs can be safely met in an alternate and lower intensity setting such as in an 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667) for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers within a reasonable distance that can provide this item.  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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of lymphedema. The treating nurse practitioner documentation is not specific that the enrollee has failed a four week trial of adequate compression of a minimum of 30mm Hg leg compression. The documentation does not support that the enrollee must go out-of-network or have a Tactile brand device with sleeve.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or in the home with home health care services.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Testing
Decision: Favorable

 We decided that the Plan has to pay for the electrocardiogram (93010) provided on April 10, 2021.  You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration because the documentation supports that this service was medically necessary. The Plan denied your request. The Plan says that this code is not separately payable.  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.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has based their denial stating that this service is inclusive to another service that has been billed. The Plan has not forwarded any evidence to indicate that another service has been billed. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the electrocardiogram (93010) provided on April 10, 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 14, 2021.  You asked the Plan to waive the copayment for an office visit. You say that you were never told you had a copayment, and the provider should have told you prior to the time of service. The Plan denied your request. The Plan says the proper copayment has been applied.  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 $25 copayment for each Medicare-covered specialist visit.   You have been asked to pay a $25 copayment for a specialist visit. An office visit falls within the Physician/Practitioner services, including doctor's office Visits 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 a specialist visit provided on June 14, 2021.   Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).  You asked the Plan to pre-approve a PET scan of the brain. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of the requested service have not been met.  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 a PET scan of the brain. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is not suspected of having FTD. The enrollee's neuropsychological testing was not consistent with AD. In this case it cannot be said that the enrollee meets diagnostic criteria for both AD and FTD, which is the preliminary basis on which Medicare covers the requested service.  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 PET scan of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for laboratory tests, a stress test, and a computerized tomography (CT) scan provided from August 30, 2021, to September 10, 2021.  You asked the Plan to waive the copayments for the laboratory tests, a stress test, and a CT scan. You say that in the past you have not been charged a copayment for these services. The Plan denied your request. The Plan says the proper copayments were applied.  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 $10 copayment for Medicare-covered laboratory tests that are not FIT tests. On September 7, 2021, the max total amount for the laboratory test was $6.47. Therefore, the copayment cannot be more then the total amount so $6.47 was charged as the copayment. Your contract with the Plan also clearly says that you must pay a $10 copayment for Medicare-covered outpatient diagnostic tests. Your contract with the Plan also clearly says that you must pay a $325 copayment for Medicare-covered diagnostic radiology services that are not ultrasounds. On September 10, 2021, the max total amount for the CT scan was $126.45. Therefore, the copayment cannot be more then the total amount so $126.45 was charged as the copayment.  You have been asked to pay a $152.92 copayment for laboratory tests, a stress test, and a CT scan. Laboratory tests, a stress test, and a CT scan falls within the Outpatient diagnostic tests and therapeutic services and Supplies 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 copayments for laboratory tests, a stress test, and a computerized tomography (CT) scan provided from August 30, 2021, to September 10, 2021.
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 stay is not medically necessary based on IRF criteria. The Plan states home
physical therapy or physical therapy at a skilled nursing facility may be covered if requested.
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 on review of the available records the enrollee with debility from acute illness in a
skilled nursing facility (SNF), is medically stable with no complications. With their comorbid conditions being
stable, he does not need 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. No acute or complex rehabilitation nursing needs noted in the record. At the current functional level
despite daily therapies in an SNF making very slow progress and they are not expected to make a significant
functional recovery in a reasonable period of time in an IRF. The enrollee does not need 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. IRF admission is not medically necessary based on lack of medical complexity, and
rehabilitation nursing needs. Document does not support the necessity for admission to an IRF. While the
enrollee may benefit from physical therapy (PT), occupational therapy (OT) and speech therapies, the enrollee's
rehabilitation needs can be safely met in an alternate and lower intensity setting such as in an SNF. The
enrollee is already appropriately admitted to an 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 a subacute rehabilitation admission.  You asked the Plan to pre-approve the subacute rehabilitation admission. You say that the enrollee must learn how to navigate safely, get out of bed, and learn how to help herself get up when she does fall in order to return to her apartment. You also say that the enrollee needs pain management. The Plan denied your request. The Plan says the enrollee has no current skilled nursing needs and the current non-skilled nursing needs can be managed at a lower level of care.  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 subacute rehabilitation admission. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the subacute rehabilitation admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a subacute rehabilitation admission.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for mobile X-Ray transportation service provided on August 11, 2021.  You asked the Plan to pay for mobile X-Ray. You say that this procedure is required to be provided onsite by the physician assigned to provide care to the patient. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the Plan may not pay for this radiology service Technical Component because it is included in the skilled nursing facility (SNF) prospective payment system (PPS) payment made to the facility.  The Plan must follow Medicare rules. Medicare rules say that a Plan may not separately pay for the Technical Component (TC) of radiology services provided to SNF inpatients.  We looked at the file and Medicare rules. This Technical Component of a radiology service is not separately payable by the Plan because the enrollee was in a Skilled Nursing Facility (SNF) stay; therefore, payment for this service is included in the SNF PPS. Based on this information, we decided that Medicare rules for coverage of mobile X-Ray have not been met. Therefore, we decided that the Plan does not have to pay for mobile X-Ray transportation service provided on August 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998), provided on July 30, 2021.  You asked the Plan to pay for the ambulance service. You say that due to the coronavirus cases in the hospital and being high risk, you decided it was best you go to your daughter's house to be monitored. You say that after the paramedics stabilized you and presented the different options, you felt that going to the hospital posed more risk due to the coronavirus cases there. The Plan denied your request. The Plan says transport was not provided on the date of service in this case. the Plan also says that since no transport was provided there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on July 30, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998), provided on July 30, 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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 more stable but remains at a poor prognosis and should only require short-term additional acute care services that can safely be received 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 a lower level of care may be considered soon when treatment has completed. 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: 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 stay is not medically necessary based on IRF criteria. The Plan states the enrollee can safely receive the services they need in other settings, for example: a skilled nursing facility (SNF) or home with home health services.

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 health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen (15) hours per week of rehabilitative services and regular physician evaluation.

The enrollee's care needs can be met 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.
You asked the Plan to pre-approve Trulicity. You say that this drug is medically necessary for your condition. The Plan denied your request. The Plan says this drug is not covered under your 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 Trulicity.
Benefits for Trulicity may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights