Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical documentation does not indicate that the enrollee's medical management and rehabilitation needs require an inpatient stay, and close physician involvement.
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 right gastrocnemius tear. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a spinal distraction device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there are currently no clinical indications for this technology.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found spinal distraction devices are experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a spinal distraction device 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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cologuard cancer screening test.
You asked the Plan to pre-approve a Cologuard cancer screening test. You say that the enrollee is requesting this screening test. The Plan denied your request. The Plan says the enrollee is over 85 years of age.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The record shows that age criteria is not met for this test. Therefore, we decided that the Plan does not have to pre-approve a Cologuard cancer screening test.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional facet joint injections.
You asked the Plan to pre-approve additional facet joint injections. You say that this request is medically necessary. The Plan denied your request. The Plan says there is no documentation presented in the medical record as to why the enrollee is not a candidate for radiofrequency ablation.
The Plan follows Medicare rules. Medicare rules say that for therapeutic facet joint injections to be covered there must be documentation as to why the patient is not a candidate for radiofrequency ablation 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 additional facet joint injections. Our reviewer says that this request is medically necessary. Our physician reviewer found the enrollee is a 67-year-old female with low back pain who has previously had prior facet joint injections that were successful. However, there is no documentation in the medical record as to why the enrollee is not a candidate for radiofrequency ablation as definitive management for her symptoms. The enrollee does not meet the LCD criteria for the requested facet joint injections.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve additional facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on April 27, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for wound care. You say that these services were medically necessary. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there is no referring 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 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 wound care provided on April 27, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the coinsurance for home health services.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was charged based on the services provided and the claim
submitted by the provider. Maximus partially overturned the Plans denial. The Plan requested a reopen. The
Plan states the $19.12 difference is due to the required 2% "Sequestration Withhold" which is $38.25. The
correct breakdown for the claim line in question due to sequestration is as follows: Enrollee responsibility
$1912.365, 2% = $38.2473 or $38.35. The claim screens show an amount of $38.25 as "Other Discount"
(which is how the sequestration is shown). Also, the "Medicare Maximum Rate" allows this fee provision.
Therefore, the claim was processed with the payment responsibility being $1912.36 coinsurance.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay 50% coinsurance for home
heath visits. 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 or reduce this cost share
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for the services you received on December 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were not authorized.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were provided for the services by a contract provider. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the services you received on December 9, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hotel stays during chemotherapy.
You asked the Plan to pre-approve hotel stays during chemotherapy. You say that chemotherapy is two hours away. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that lodging and transportation costs are only covered when there is an approved transplant service. We looked at the file and Medicare rules. Review of the file shows that you are requesting hotel stays for chemotherapy services for the enrollee. Hotel stays are only covered for an approved transplant service. Based on this information, we decided that Medicare rules for coverage of hotel stays during chemotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hotel stays during chemotherapy.
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 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 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. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient sub-acute rehabilitation services for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee needs a little help getting bathed and dressed. The Plan denied your request. The Plan says a safe transition to home with family assistance can be made.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee is at a high functional level.
The enrollee is medically stable after a recent fall and C3 fracture. There are no neurological deficits. There is
no need for daily skilled nursing care, IV medications, or wound care. Daily skilled therapies in an inpatient
setting are not needed. The documentation does not support the need for an admission to skilled nursing
facility. The enrollee's rehab needs can be met at a lower intensity level such as in home with services or in an
assisted living facility with intermittent therapies as needed.
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 inpatient sub-acute rehabilitation services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint nerve treatment/radiofrequency ablation (RFA) 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 based on the policy and currently available information, the current request is not medically necessary and cannot be approved at this time.
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 issue with this case is that two procedures were done on the same day. Therefore, it is impossible to discern which block is responsible for the pain relief. The request is deemed not medically 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 facet joint nerve treatment/radiofrequency ablation (RFA) for the enrollee.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the 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 necessitating 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 present setting 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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facility services (99053) provided on February 27, 2021.
You asked the Plan to pay for facility services. You say that this was billed correctly. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) status indicator of B on a procedure code indicates payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. The code at issue, 99053, has a status indicator of B, meaning payment for this service is bundled into payment for other services. Based on this information, we decided that
Medicare rules for coverage of facility services have not been met. Therefore, we decided that the Plan does not have to pay for facility services (99053) provided on February 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for multivitamin injections (J3490 and J7999) provided on March 18, 2021.
You asked the Plan to pay for the multivitamin injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the billed services do not meet Medicare criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes J3490 and J7999 are not supported in the medical record. Specifically, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. Additionally, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. As this compounded drug was not billed properly, payment cannot be made. Based on this information, we decided that Medicare rules for coverage of the multivitamin injections have not been met. Therefore, we decided that the Plan does not have to pay for multivitamin injections (J3490 and J7999) provided on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic (D6240) and retainer crowns (D6750).

You asked the Plan to pre-approve the pontic (D6240) and retainer crowns (D6750). The Plan denied your request. The Plan says the services are not covered benefits.

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 the pontic (D6240) and retainer crowns (D6750).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve pancreas transplant evaluation services.

You asked the Plan to pre-approve pancreas transplant evaluation services. You say that the medical records
provided support the need for the requested services. The Plan denied your request. The Plan says that the
services requested are not deemed medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.

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 pancreas transplant evaluation services.
Our reviewer says that pancreas transplant evaluation services are considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee has had all the complications from
longstanding Type 1 diabetes and they are all severe and debilitating in nature. The enrollee is an ideal
candidate for pancreas only transplant. The best way to manage preventing further severe complications is with
transplant. A transplant is medically indicated and justified.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of pancreas transplant evaluation services have been met. Therefore, we decided
that the Plan has to pre-approve pancreas transplant evaluation services.

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.