Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility services.  You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not 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 the skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility 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 the SNF services. You say that if you don't receive treatment in the SNF your respiratory system will fail and result in a loss of oxygen, causing brain injury or death. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee's needs can be met at an alternate level of 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital.  The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis.  He is medically stable and can receive further rehabilitation services at a lower level of care.  Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube.  He is medically stable without any acute exacerbations of chronic medical problems.  His physical function is at or near his baseline and he can receive services at a lower level of care.  Admission to a SNF for inpatient skilled rehabilitation services is 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 the 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided on July 14, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you were referred to a specialist in wound care and debridement was performed not medication administration. You say that the medication administration was performed by your daughter not the doctor. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on July 14, 2021.   Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 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 enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF or that the patient can tolerate an intensive level of therapy.  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 acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level or can be tolerated on an intensive level 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.  You asked the Plan to pre-approve SNF services. You say that the enrollee needs physical therapy to restore her strength. The Plan denied your request. The Plan says that the patient's needs are custodial.  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 necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you would like the IRF admission covered. The Plan denied your request. The Plan says you do not meet criteria for an IRF admission.  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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 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 memory foam mattress for the enrollee.  You asked the Plan to pre-approve a memory foam mattress. You say that the member has had lower back pain for 10 years and that it is unresponsive to steroid epidural and physical therapy. The Plan denied your request. The Plan says that Medicare does not cover mattresses unless they are part of a hospital bed.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a memory foam mattress for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that there is fear of harm or death if the enrollee does not go to the SNF. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  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 daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgement of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 were active prior to the stroke and your potential for recovery is excellent given your previous active lifestyle. You say that your entire care team agrees that you need placement in an acute rehabilitation facility. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's needs can be met at an alternate 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. Her blood pressure, thyroid function, and kidney function are stable. Her cardiologist was comfortable with discharging her. Her neurologic status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level 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 waive the copayments for each application of multi-layer compression system of the leg at an outpatient hospital (29581, G0463, 97598) rendered from April 2, 2021, to May 21, 2021.  You asked the Plan to waive the copayments for each application of multi-layer compression system of the leg at an outpatient hospital. You say that the enrollee did not have surgery, he just had wound dressing for his legs. You also say that this is the exact same service he receives at no cost from his home care nurse. You also say that the enrollee would never have agreed to this treatment at this price and that he was never told what the price would be. The Plan denied your request. The Plan says you were 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $400 copayment per visit for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   The enrollee has been asked to pay a $353.71 copayment for the application of multi-layer compression system of the leg in an outpatient hospital on April 2, 2021. You also have been asked to pay a $353.71 copayment for the application of multi-layer compression system of the leg at an outpatient hospital on April 9, 2021. You also have been asked to pay $226.33 for application of multi-layer compression system of the leg in an outpatient hospital on April 23, 2021. You also have been asked to pay a $353.71 copayment for the application of multi-layer compression system of the leg at an outpatient hospital on May 7, 2021. You also have been asked to pay a $226.63 copayment for the application of multi-layer compression system of the leg in an outpatient hospital on May 14, 2021. You have also been asked to pay $75.54 for the application of multi-layer compression system of the leg in an outpatient hospital on May 21, 2021. All of these copayments, which total $1,589.93 ($353.71 + $353.71 + $226.33 + $353.71 + 226.63 + $75.54 = $1,589.63), are less than the $400 copayment for each application of multi-layer compression system of the leg in an outpatient hospital. The records also show that the application of multi-layer compression system of the leg falls is a surgical procedure. The application of multi-layer compression system of the leg in an outpatient hospital falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for each application of multi-layer compression system of the leg at an outpatient hospital (29581, G0463, 97598) rendered from April 2, 2021, to May 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of acute inpatient rehabilitation facility (IRF) services from November 28, 2021, onward.  You asked the Plan to pre-approve continued IRF care. You say that additional inpatient rehabilitation is medically necessary for this enrollee. The Plan denied your request. The Plan says he criteria for continuation of IRF care are not met. The enrollee can be discharged to a lower level of care as of November 28, 2021.  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 continued IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found the enrollee's current medical stability and lack of documented medical complexity do not require physician supervision at least three times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute rehab nursing care needs. Based on the enrollee's current level of function, she does not require ongoing intensive therapies, consisting of at least three hours per day five days per week with a multidisciplinary approach to daily therapy. Continuation of IRF care is not medically necessary. The enrollee's ongoing physical and occupational therapy needs can be safely met in an alternate and lower intensity 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 continued IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of acute inpatient rehabilitation facility (IRF) services from November 28, 2021, onward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve prosthetic items to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the OON prosthetic items. You say that the enrollee's current prosthesis is ill-fitting, rendering him immobile and a fall risk. You say that you are the only company willing to travel to the enrollee's home and meet his immediate needs. The Plan denied your request. The Plan says there are in-network providers of lower extremity prostheses that are available to fulfill the request within a reasonable distance of the enrollee's location.  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. There is no evidence that the enrollee is homebound. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested items with an out of network provider. Therefore, we decided that the Plan does not have to pre-approve prosthetic items to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.  You asked the Plan to pre-approve the compression stockings. You say that you are a diabetic and you feel you need the compression stockings to prevent blood clots in your legs. Your doctor believes you should be able to get compression socks. The Plan denied your request. The Plan says the requested item is not a covered benefit.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.   Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.