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.  You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the requested IRF care is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the requested IRF care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member's medical problems are stable. There are no complex nursing or rehabilitation needs.  The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this member 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22867), for the enrollee.

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 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 the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has lumbar spinal stenosis with radiculopathy. The record indicates that the requested procedure is for level L4-L5. The record indicates that the enrollee has imaging findings of a previous right L4 hemilaminectomy and advanced facet arthropathy. The record does not indicate that the enrollee will not requires extensive debridement of the advanced facet arthropathy. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22867), 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.  

You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria for the requested IRF care.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your 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. There is no documentation of a need for an intensive 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a full 10 month rental of a manual wheelchair.  You asked the Plan to pre-approve the services. You say that this is medically necessary based on unspecified fracture of left lower leg, subsequent encounter for closed fracture with routine healing. The Plan denied your request. The Plan says a full 10 month capped rental is not reasonable or necessary.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is unclear as to why your mobility deficit is unable to be helped by crutches. The documentation includes an undated home assessment and it is not clear who performed the assessment. The document states there is plenty of room for a 20 inch manual wheelchair. The home assessment does not indicate floor surfaces, or room for turning radius. It is not clear from the documentation whether a manual wheelchair will significantly improve your ability to participate in MRADLs. The x-rays also reveal that your fracture is healing. The documentation does not support that you will be non-weight-bearing beyond three months; therefore at this time, you do not require a wheelchair for beyond the three months approved by the health plan. You can be reassessed by the physician to be re-evaluated on your weight bearing status, which will determine the need for ongoing use of this wheelchair. At this time, ongoing coverage of the requested wheelchair is not reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a full 10 month rental of a manual wheelchair.
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 you continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation doesn't support that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your functional status. You can receive further care 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network oncologist.  You asked the Plan to pre-approve these services. You say that this provider specializes in breast cancer. The Plan denied your request. The Plan says the services are available from network providers.  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 referral to an out-of-network oncologist.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient mental health services received from February 18, 2021 to March 18, 2021.  You asked the Plan to waive the copayment for the outpatient mental health services. You say that you are being incorrectly billed for services. The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.  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 outpatient mental health.    Review of the file shows that you received outpatient mental health services on February 18, 2021, February 25, 2021, and March 18, 2021. You have been asked to pay a $40 copayment for each individual/group therapy session, for a total of $120. The outpatient mental health services fall within the outpatient mental health 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 the outpatient mental health services received from February 18, 2021 to March 18, 2021.   We note that you received an invoice for the $186 for services that were not covered. The Plan has stated that they have reached out to the provider so that you will no longer receive an invoice for the non-billable total of $186.00
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network ear, nose, and throat specialist (otolaryngologist).  You asked the Plan to pre-approve these services. You say that this doctor was recommended by your pulmonologist. The Plan denied your request. The Plan says the services are available from network providers.  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 referral to an out-of-network ear, nose, and throat specialist (otolaryngologist).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you would like reconsideration because the requested SNF care is medically necessary. The Plan denied your request. The Plan says that the member does not meet Medicare coverage criteria for the SNF 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 care. Our reviewer says that the beneficiary does require skilled nursing or therapy services on a daily basis. Our physician reviewer found this beneficiary does meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

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: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the office or other outpatient visit for the evaluation and management of an established patient (CPT code 99214) and impression and custom preparation; oral surgical splint (CPT code 21085).  

You asked the Plan to pre-approve the services. You say that the enrollee presented with limited mouth opening as well as facial pain and requested stabilization orthotic as part of the enrollee's treatment plan for trismus and temporomandibular joint dysfunction (TMJ) disorder. The Plan denied your request. The Plan says oral appliances, including TMJ splints, are dental devices that are not covered. The Plan states this applies whether the devices to treat TMJ or other conditions such as trismus.    

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Medicare determined that oral appliances, including TMJ splints, are dental devices that are not covered. This applies whether the devices to treat TMJ or other conditions such as trismus. This decision does not address the medical necessity or appropriateness of the requested drug or service. It only establishes that payment cannot be made under Medicare regulations. We based our decision on the Medicare Coverage Article titled Oral Appliances for Obstructive Sleep Apnea - Policy Article (A52512). This Coverage Article states, "Oral appliances generally are classified as dental devices and are not classified as durable medical equipment." Therefore, we decided that the Plan does not have to pre-approve the office or other outpatient visit for the evaluation and management of an established patient (CPT code 99214) and impression and custom preparation; oral surgical splint (CPT code 21085).
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 will clearly benefit from acute rehabilitation to optimize his level of functioning prior to returning home. The Plan denied your request. The Plan says the records received do not indicate that the enrollee needs an intensive therapy program with multiple visits from a rehabilitation doctor per week. The Plan also says that 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.  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 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 coronary artery bypass grafting Medical problems are stable. There are no complex nursing or rehabilitation needs. Our reviewer found that the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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. Our physician reviewer also found that there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 stay is not medically necessary based on LTACH 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 was admitted with Coronavirus (COVID-19) pneumonia and developed acute hypoxic respiratory failure requiring mechanical ventilation. The record indicates that the enrollee is improving but still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.

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 office visit, manual therapy techniques, and therapeutic procedure provided on August 11, 2021 and August 13, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit, manual therapy techniques, and therapeutic procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit, manual therapy techniques, and therapeutic procedure provided on August 11, 2021 and August 13, 2021 by an out-of-network (OON) provider.