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 the enrollee needs inpatient rehabilitation. The Plan
denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing
skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a supply allowance for therapeutic continuous glucose
monitor (CGM) (K0553).
You asked the Plan to pre-approve the CGM supply allowance. You say that you were informed that the arm
sensor would be covered by the Plan when you signed up. The Plan denied your request. The Plan says you are
not currently using insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing
results. Based on this information, we decided that Medicare rules for coverage of the CGM supply allowance
have not been met. Therefore, we decided that the Plan does not have to pre-approve a supply allowance for
therapeutic continuous glucose monitor (CGM) (K0553).
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 enrollee has had a very long,
complicated hospital course and would be best served in an LTACH for ongoing care. The Plan denied your
request. The Plan says the criteria for admission to an LTACH are not met. The enrollee can adequately receive
the care needed for ongoing ventilator weaning in the current location. The enrollee is not required to discharge
elsewhere to receive ongoing acute level care. All services that would be provided in the LTACH are being
provided in the current acute care setting which is already approved. Therefore, the request for admission to an
LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided indicating medical necessity for admission to a
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where 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. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: 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 the enrollee is too weak to be by herself. The
Plan denied your request. The Plan says the services the enrollee requires can safely be received at a different
setting.
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 the enrollee does not have documented skilled nursing or skilled therapy needs. Daily skilled
services are not shown to be required to establish a maintenance program or to prevent deterioration of the
enrollee's condition.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve a PET scan. The Plan denied your request. The Plan says the study is not
needed to differentiate Alzheimer's from frontotemporal dementia.
The Plan follows Medicare rules. Medicare rules say that PET scans for dementia and neurodegenerative
diseases are only covered under certain medical indications.
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. Our physician reviewer
found that in this case, the request is for a beta amyloid PET scan. This service is currently only covered in the
context of an approved clinical study. This request for the imaging study is not otherwise part of a research
protocol. In as much this service would not be eligible for 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 a PET scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildups (D2950) and porcelain/ceramic crowns
(D2740) for teeth #9, #10, and #11.
You asked the Plan to pre-approve the core buildups and crowns. You say that these services are necessary.
The Plan denied your request. The Plan says the requested services are not covered by the Plan's dental benefit.
Up to two crowns may be covered each year; however, the specific porcelain/ceramic crowns (D2740)
requested are not among those covered by this benefit.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core
buildups (D2950) and porcelain/ceramic crowns (D2740) for teeth #9, #10, and #11.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an oral device to be provided to the enrollee by an out-of-network (OON) provider.  You asked the Plan to pre-approve an oral device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item can be provided to the enrollee by a network provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an oral device to be provided to the enrollee by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need
additional rides beyond the 24 rides offered for doctor's appointments. The Plan denied your request. The Plan
says you have exhausted the maximum benefit of 24 one-way trips 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 24 one-way trips per year.
We looked at your request, the records in the case file, and the rules. The records show that you have used 24
one-way transportation trips this year. 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
provide coverage for additional routine transportation trips (A0120)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 29, 2021,
forward.
You asked the Plan to pre-approve inpatient psychiatric care from November 29, 2021, forward. You say that
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue
are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient psychiatric care from
November 29, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient
mental health treatment beyond the date in question of November 29, 2021, forward. Our physician reviewer
found the enrollee did not require inpatient mental health treatment beyond November 29, 2021, as she was not
a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear
that active treatment was taking place beyond the date in question. It did not appear that the services for the
dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for
the purpose of diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care from November 29, 2021, forward have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 29,
2021, forward
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 do not require treatment by multiple therapies, including either physical therapy
or occupational therapy, and an intensive rehabilitation therapy 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a gastric peroral endoscopic myotomy (G-POEM) with inpatient admission.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that an endoscopy is covered when specific criteria are met. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have gastroparesis and a gastric peroral endoscopic myotomy (G-POEM) is planned. There is insufficient medical literature to support the use of this procedure for your condition. You do not have a condition for which for the G-POEM procedure is covered. The services are therefore not reasonable or medically necessary. Given that the procedure is not medically necessary, the inpatient admission is also 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a gastric peroral endoscopic myotomy (G-POEM) with inpatient admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for inpatient mental health services provided
from July 16, 2021, through July 22, 2021.
You asked the Plan to reduce the copayment for the inpatient mental health services. You say that you wanted
to leave the hospital, but the hospital did not let you. You say you should not have been in the hospital that
long, so your bill should be lower. The Plan denied your request. The Plan says you have been charged the
correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95
copayment per day for days 1-5 per admission.
You have been asked to pay a $95 copayment for each of the first five days of the inpatient mental health
admission, for a total of $475 ($95 copayment x 5 days = $475). The inpatient mental health services fall
within the Inpatient Mental Health Care 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 reduce the copayment
for inpatient mental health services provided from July 16, 2021, through July 22, 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 you need intensive therapy to get stronger as quickly as possible, and you are concerned that your functional mobility will decrease if you are sent to a skilled nursing facility. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can receive the services you need in an alternate setting.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that based on the medical records provided, 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 do require physical therapy and occupational therapy services, but based on the medical records provided, you do not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided, there is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to your fatigue and dyspnea with exertion. Care at the skilled nursing facility level appears to be appropriate in this case.       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 a continued inpatient psychiatric admission from December 6, 2021, forward.  You asked the Plan to pre-approve a continued inpatient psychiatric admission. You say that the service is medically necessary. The Plan denied your request. The Plan says under Medicare guidelines, the request is not medically necessary because the records received show that the enrollee's condition has improved, and she is no longer a threat to herself or others.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 continued inpatient psychiatric admission. Our reviewer says that a continued inpatient psychiatric admission from December 6, 2021, forward is not medically necessary. Our physician reviewer found that this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others, no auditory hallucinations or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. It appears that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of December 6, 2021, forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was not showing any aggressive behaviors or any treatment required for acute threats of safety as the enrollee awaited placement.  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 continued inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from December 6, 2021, forward.