Persius/hicric huggingface dataset:
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the member is able to get the necessary rehabilitation, such as physical
therapy and occupational therapy at the skilled nursing level of care with the goal of safely returning member
to home.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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. The
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lumbar laminectomy
and posterior fusion. The enrollee's medical conditions are stable. There are no medical needs requiring
inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the medical record documents a need for physical and occupational
therapy, it does not document 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. Our physician reviewer found that the enrollee's condition does not meet
Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.

You asked the Plan to pre-approve Aranesp. You say that this is medically necessary for treatment of the patient's chronic kidney disease. The Plan denied your request. The Plan says that there is no indication the step therapy drugs would likely be less effective, and/or cause adverse effects for the member.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Retacrit. There is no documentation provided indicating that Retacrit would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Aranesp. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99204) electronic analysis of
programmable, implanted pump for intrathecal or epidural drug infusion (62368) provided on September 30,
2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you were put into palliative care and one of the
doctors was this provider. They assured you that they accepted the plan so you did not see any problem with
going forward. The Plan denied your request. The Plan says enrollee's must receive their medical services from
an in-network provider with the exception being urgent or emergent services. Non-emergent services with noncontracted
providers require prior authorization before services being rendered.
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 has network providers
available who can provide 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 outpatient office visit (99204) electronic analysis
of programmable, implanted pump for intrathecal or epidural drug infusion (62368) provided on September 30,
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided on September 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that you have enclosed the supporting medical records to prove the need for the services rendered to be paid to the provider of service. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 has network providers available who can provide 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 the subsequent nursing facility care (99310) provided on September 3, 2020 by an out of network (OON) provider.
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 the stay is medically necessary. The Plan
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not
require transfer to LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee's medical needs are being met in the current acute setting. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on April 7, 2021.
You asked the Plan to pay for the lab testing. You say that this should be reprocessed based on medical necessity. The Plan denied your request. The Plan says this is not separately payable according to Medicare rules.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab testing provided on April 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the services could be provided in another setting, such as an acute rehab
facility, skilled nursing facility, nursing facility, outpatient setting, or home care.
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 necessitating admission to a LTACH. The
enrollee's medical needs are being met in the current acute setting. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where he is 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. There are no requested LTACH services that are 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from April
2, 2021, to May 6, 2021.

You asked the Plan to pay for home health services. You say that you would like reconsideration because you
have been paid all through 2020 without a RAP. The Plan denied your request. The Plan says no RAP has been
submitted for these services.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the record
indicates that a RAP has not been submitted for the billed home health services. Therefore, we decided that the
Plan does not have to pay for the home health services provided to the enrollee from April 2, 2021, to May 6,
2021.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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 does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab needs can be safely provided in an alternate and lower intensity setting such as in a skilled nursing facility.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance transportation services (A0429) provided on March 11, 2021.

You asked the Plan to pay for the ambulance services. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says this claim has not been billed correctly.

The Plan must follow Medicare rules. Medicare rules say when an enrollee is pronounced dead after the ambulance has already been called there are specific coding regulations to follow as listed in the Medicare rules section. 

We looked at the file and Medicare rules. In this case, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transportation services (A0429) provided on March 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional skilled nursing home health services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare's homebound criteria.
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 the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found in this case, the documentation doesn't support that the enrollee requires additional skilled nursing services to provide treatment that is medically necessary. The enrollee does not require additional skilled nursing to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Additionally, the documentation does not support that the enrollee is currently home bound.
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 additional skilled nursing home health services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on September 20, 2021.

You asked the Plan to pay for a comprehensive oral evaluation. You say that you do not agree with the denial. The Plan denied your request. The Plan says you previously met your benefit limit for this service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a comprehensive oral evaluation once every 36 months. 

We looked at the file and Medicare rules. The records show that you received a comprehensive oral evaluation on September 16, 2021, therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on September 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you are appealing this notification and requesting reconsideration with the attached records. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 has network providers available who can provide 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 the laboratory services provided on July 7, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
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. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee's medical needs are being met in the current acute setting. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for respiratory failure and COVID 19 pneumonia. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.