Persius/hicric huggingface dataset:
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 a LTACH admission is medically necessary. The Plan denied your request. The Plan says the member is receiving appropriate inpatient care and does not require transfer to a 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 that there is no documentation provided indicating medical necessity for the requested LTACH services. 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 she 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.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is not safe to go home at the current level and needs continued physical and occupational therapy. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF admission does not meet the requirements for approval.
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 based on review of the available records, the enrollee with an uncomplicated hip fracture, post-surgery does not meet Medicare coverage criteria for an IRF admission. At the current medical stability and lack of medical complexity, there is no need for a physical medicine and rehabilitation physician
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no documented skilled nursing needs. The documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The enrollee will not be able to tolerate the intensity of therapies in an IRF and will not be able to meet the Medicare expectation of making a significant functional progress in a predicted and reasonable period of time based on the enrollee's current function and participation. An IRF admission is not medically necessary based on lack of current medical complexity and lack of skilled nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the enrollee's therapy needs can be addressed at a lower intensity level such as 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Skilled Nursing Facility services billed with GAGD1 x 16 on March 1, 2020, through March 17, 2020.
You asked the Plan to pay for the Skilled Nursing Facility services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says The Nursing Admission Functional Assessment Section GG forms received do not include the clinician signature and cannot be used to support assessment coding.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 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 pay for the Skilled Nursing Facility services. Our reviewer says that the documentation does not support the billing of GAGD1 x 16 days. Our physician reviewer found the documentation only includes physical therapy notes and does not include a physician
signature to verify the 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 Skilled Nursing Facility services have not been met. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility services billed with GAGD1 x 16 on March 1, 2020, through March 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0297), for the enrollee.
You asked the Plan to pre-approve the total electric hospital bed. You say that the enrollee is unable to stand/walk without full support. The Plan denied your request. The Plan says the height adjustment feature is a convenience feature.
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 total electric hospital bed have not been met. The rules say that a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0297), 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 that you are currently in the hospital due to having an emergency surgery that resulted in having your leg amputated. You say that you would like to start the rehabilitation process as soon as possible because you are also a caregiver for your 95-year-old mother, and you will need extensive therapy in order to regain your strength and relearn how to do a lot of things that affect your everyday life. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and a lower level of care might be appropriate.
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 based on review of the available records, you do not meet Medicare coverage criteria for an IRF admission. You are medically stable with new below-knee amputation and medical complexity. You do not need a physical medicine and rehabilitation physician's supervision 3 times a week. There are no documented skilled nursing needs. The medical documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. IRF admission is not medically necessary based on lack of current medical complexity and lack of skilled nursing needs. While you may benefit from physical therapy and occupational therapy, your therapy needs can be addressed at a lower intensity level such as 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested CGM.

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 the enrollee does not perform blood glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not 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 a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cochlear device implantation, with or without mastoidectomy.
You asked the Plan to pre-approve cochlear device implantation, with or without mastoidectomy. You say that the requested surgery is medically necessary. The Plan denied your request. The Plan says the requested surgery is not medically necessary and does not meet Medicare guidelines.
The Plan follows Medicare rules. Medicare rules say that cochlear implantation may be covered for individuals meeting the selection guidelines and with hearing test scores of greater than 40%. 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 cochlear device implantation, with or without mastoidectomy. Our reviewer says that the requested cochlear device implantation, with or without mastoidectomy does not meet the Medicare guidelines. Our physician reviewer found that cochlear implantation may be covered for treatment of bilateral pre- or-post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification, defined by test scores of less than or equal to 40% correct in the best-aided listening condition on tape-recorded tests of open-set sentence cognition. The documentation in the case file does not support that the enrollee has test scores of less than or equal to 40% correct in the best-aided listening condition on tape-recorded tests of open-set sentence cognition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cochlear device implantation, with or without mastoidectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve cochlear device implantation, with or without mastoidectomy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeomin botulinum injections.

You asked the Plan to pre-approve the Xeomin botulinum injections. You say that you would like reconsideration because the member has chronic pain with dystonia. The Plan denied your request. The Plan says there is no documentation of a covered condition for the requested procedure.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Xeomin botulinum injections. Our reviewer says that the documentation does not support that the coverage criteria for Xeomin have been met for the enrollee 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 the Xeomin botulinum injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Xeomin botulinum injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan
denied your request. The Plan says your medical records show you are medically stable, and your current level
of physical function has improved with therapy. It is not medically necessary for you to require daily inpatient
physical/occupational therapy and your needs can be met with intermittent physical/occupational therapy 3-4
times per week at a lower level of care at home or a custodial level.
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 reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found based on the medical records
provided there is no documentation that you require skilled nursing services, i.e., the specialized skill,
knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide
medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized
skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically
necessary and reasonable treatment. However, daily skilled services are not required. Therapy 3-5 times per
week is recommended in the available records. As a practical matter, you do not require the services on an
inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis
appear 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve SNF services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular/extraarticular knee radiofrequency ablation (CPT code 64624), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says there is not enough medical proof that shows the safety and/or success of genicular/extra-articular knee radiofrequency ablation. The Plan state this type of surgery is considered experimental and/or unproven.
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 enrollee notes bilateral knee pain that has successfully controlled with extra-articular and genicular knee blocks with radiofrequency ablation. However, detailed documentation is not evident regarding the specific benefit with the most recent procedure on August 24, 2020. In addition, there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of these procedures for this enrollee. Therefore, the request for genicular/extra-articular knee radiofrequency ablation (CPT 64624) is not medically reasonable and 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular/extraarticular knee radiofrequency ablation (CPT code 64624), for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee arthroplasty, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) (CPT code 27447).
You asked the Plan to pre-approve the knee arthroplasty. You say that you have bone on bone. You state that you were told typically you have to have three (3) months of physical therapy but that will not work due to your knee being bone on bone. You state injections do not fix bone on bone and you cannot walk. The Plan denied your request. The Plan says the documentation submitted does not show you have completed three (3) months of conservative treatment or that conservative treatment is not appropriate for you.
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 knee arthroplasty. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella resurfacing (total knee arthroplasty) (CPT code 27447) does not meet the requirements listed in the LCD for Medicare coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee arthroplasty, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) (CPT code 27447).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the synovectomy with lysis of adhesions.

You asked the Plan to pre-approve the synovectomy with lysis of adhesions. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the requested procedure.

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 synovectomy with lysis of adhesions. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. There is limited documentation to demonstrate an intensive physical therapy program. In addition, his range of motion is noted to be 0-115. The requested procedure is not supported in this clinical scenario. 

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 synovectomy with lysis of adhesions have not been met. Therefore, we decided that the Plan does not have to pre-approve the synovectomy with lysis of adhesions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for Medicare Part B drugs provided on March 23, 2021.

You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for Medicare Part B drugs. You say that you have never been charged this much in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment for specialist services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 

You had a specialist visit on March 23, 2021. Therefore, you are responsible to pay the $35 copayment. 

You received Medicare Part B drugs on March 23, 2021. The total allowed amount is $3,022.86 and 20% of that is $604.57. 

The total amount you owe is: $639.57. 

You have been asked to pay the total amount of $639.57 for a specialist visit and Medicare Part B drugs. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 a specialist visit and does not have to waive the coinsurance for Medicare Part B drugs provided on March 23, 2021.