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 enrollee still needs the rehabilitation services in order to gain maximum strength and quality of life. The Plan denied your request. The Plan says the enrollee's records show that they do not require supervision of a rehabilitation doctor at least three times per week, the enrollee is not likely to improve a lot in a reasonable amount of time, the enrollee is not likely to tolerate 3 hours of therapy, five (5) days per week, and the enrollee does not require aggressive therapies by an intensive team in order to properly regain their function. The Plan states the enrollee can safely receive the services they need in other settings, for example: a skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.
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 pneumonia and a urinary tract infection. 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 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips. 
 
You asked the Plan to pre-approve additional transportation trips. You say that you need transportation to 
medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number of 
transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 20 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation trips.
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.
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 after a fall and was treated for acute on chronic renal failure, requiring hemodialysis, respiratory failure, pneumonia, metabolic acidosis, third degree heart block requiring pacemaker placement, transient ischemic attack, and a fibular fracture not requiring surgery. 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 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 IRF admission and services.
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 you need assistance with walking. The Plan denied your request. The Plan says the services are not reasonable and necessary without evaluation for wound 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 SNF services. Our physician reviewer found that you have a new abscess over the sternal wound and lower extremity wound that may need a higher level of care than a skilled nursing facility. Your physical function is at or near your new baseline. You do not require skilled nursing and/or skilled therapy services on a daily basis. Admission to a SNF for inpatient skilled rehab services is not medically necessary. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Verebroplasty and Kyphoplasty) to inject cement
into a broken bone in the enrollee's back (CPT code(s): 22512, 22510, 22513, 22514, 22515, 22511), for the
enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee has a computed tomography (CT)
chest/abdomen/pelvis and that showed a new compression fracture deformity of the T-12 vertebral body. The
Plan denied your request. The Plan says the request for multiple spinal procedures, kyphoplasty or
vertebroplasty, are not medically necessary. The Plan states the documentation does not support multiple
symptomatic spinal compression fractures for which multiple procedures would be indicates. The Plan states
the compression fractures found on CT scan in August 2021 at T-12 is not associated with a change in the
character or worsening of the member's chronic back pain. The Plan states there is no documentation of
moderate to severe pain with 25% vertebral height loss, kyphosis, or a decline in daily functioning.
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 services. Our physician reviewer
found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive
less invasive conservative care measures for the compression fracture. In addition, there are no provided
examinations that demonstrate any subjective and objective deficits as directly related to the compression
fracture. There is no compelling rationale presented or extenuating circumstances noted to support the medical
necessity of this request as an exception. The medical records provided do not meet the requirements listed in
the LCD for Medicare coverage.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Verebroplasty and Kyphoplasty) to inject cement into a broken bone in the enrollee's
back (CPT code(s): 22512, 22510, 22513, 22514, 22515, 22511), for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography guidance for placement of radiation therapy fields (77014) provided from March 15, 2021, to March 26, 2021.
You asked the Plan to pay for the computed tomography services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says no medical records were submitted which support the procedures as billed.
The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the
amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were provided as billed. Based on this information, we decided that Medicare rules for coverage of the computed tomography services have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography guidance for placement of radiation therapy fields (77014) provided from March 15, 2021, to March 26, 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 you need this because you have chronic illnesses 
including heart failure. You state you are rill and recovering from chemo pneumonia because of chronic failure. 
You state you were hospitalized, not able to go to the bathroom and you are really weak. The Plan denied your 
request. The Plan says your records show you would benefit from continued therapy to improve your functional 
abilities. The Plan states your records show that your rehabilitation needs do not require an intensive team for 
you to reach your functional goals. The Plan states the records received do not support that you require an 
intensive therapy program with multiple visits from a rehabilitation doctor per week or that you are able to 
actively participate in and benefit from intensive therapy 15 hours per week. The Plan states you can safely 
receive the services you need in other settings, for example: continued skilled nursing facility admission or 
home with home health and home therapy. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for. 
respiratory failure, pneumonia, sepsis and congestive heart failure Medical problems are stable. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 you 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307) provided on August 19, 2020 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your 
request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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) provided on August 19, 2020 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the Prolia injection and the injection 
administration services you received at a specialty clinic on May 5, 2021. 
 
You asked the Plan to waive the copayments for the Prolia injection and the specialty clinic visit. You say that 
you were told there would be no charge for this. The Plan denied your request. The Plan says you were charged 
these copayments correctly. 
 
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 $50 
copayment for Medicare Part B drugs administered by a provider and a $30 copayment for specialty services.  
 
You have been asked to pay a $50 copayment for the Prolia injection and a $30 copayment for the specialty 
clinic visit. The Prolia injection falls within the Medicare Part B drugs administered by a provider benefit 
category. The specialty clinic administration services fall in the specialist services benefit category. This means 
that you have been asked to pay the correct amounts 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 Prolia injection and the injection administration services you 
received at a specialty clinic on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a cardiologist
on June 22, 2021.
You asked the Plan to waive the copayment for the cardiology visit. You say that you were advised to have
follow-up visits after you were discharged from the hospital. The first few follow-up visits with were
Physician's Assistants (PAs), so you had no copayments. When you scheduled your next visit, the PAs were not
available, so you were scheduled with a cardiologist instead. Because of this, you were charged a $40
copayment. You believe this copayment should be waived because you were scheduled with the doctor
incorrectly. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $40
copayment for visits with a specialist.
You have been asked to pay a $40 copayment for the cardiology visit. You had a visit with the cardiology
specialist who you saw while you were in the hospital. This copayment applies regardless of how you were
scheduled for this follow-up visit. 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 office visit you
had with a cardiologist on June 22, 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 enrollee needs the procedure done and a month
would be too long to wait. The Plan denied your request. The Plan says the enrollee's records show they would
benefit from continued therapy. The Plan states the enrollee's records show 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 the enrollee requires 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 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 care and home therapy.
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 congestive heart failure, urinary tract infection, and chronic foot ulcers. 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 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Push-rim activated power assist (E0986). 
 
You asked the Plan to pre-approve a push-rim activated power assist. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a push-rim activated power assist device (E0986) for 
a manual wheelchair is covered if all the criteria 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 Push-rim activated power assist. 
 
Our reviewer says that the item is not medically necessary. Our physician reviewer found the records show 
weakness of the upper extremity that will likely worsen over time. The enrollee would not be able to manually 
move the wheelchair even with power assist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Push-rim activated power assist have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Push-rim activated power assist (E0986).
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.
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 hypoxemia and respiratory failure. 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 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 IRF admission and services.