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 would benefit from IRF services. The Plan denied your request. The Plan says admission to an IRF was denied as not meeting criteria, 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 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.
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 the 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: 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 want to return to being independent. The Plan
denied your request. The Plan says you do not require an intensive multidisciplinary approach to daily therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that you were admitted to the acute care hospital for a flare of ulcerative colitis, including sepsis, abscess, deep
vein thrombosis and acute kidney injury, which resulted in a total colectomy. Your medical problems are
stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on April 26, 2021, by an
OON provider.

You asked the Plan to pay for pain management services. You say that you would like this claim reprocessed
and paid. You say that these services were medically necessary. The Plan denied your request. The Plan says
prior authorization was not obtained for these services. The Plan says that there are in-network physicians
available to provide these services.

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 pain management services provided on April 26,
2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve CPAP device. You say that you feel that this is medically necessary. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee has a CPAP device which is under recall by the manufacturer and is within its reasonable useful lifetime, so the enrollee should work with the equipment provider and manufacturer for replacement or repair.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover replacement of durable medical equipment during its reasonable useful lifetime, which in no case can be less than 5 years. We looked at the file and Medicare rules. The enrollee currently has a CPAP device which is under recall by the manufacturer, is within its reasonable useful lifetime, and has not sustained irreparable harm or damage. The enrollee should attempt to have this device repaired prior to attempting to obtain a new device. Based on this information, we decided that Medicare rules for coverage of CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care, provided on January 14, 2021, through January 29, 2021.

You asked the Plan to pay for the SNF care provided on January 14, 2021, through January 29, 2021. You say that the service was medically necessary. The Plan denied your request. The Plan says the service was not medically necessary.

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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not require and skilled nursing or skilled therapy 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 SNF care have not been met. Specifically, medically necessary services could have been obtained at a lower level of care. This means the SNF care was not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care, provided on January 14, 2021, through January 29, 2021.
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 will require reconditioning and endurance building. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer.

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 physician reviewer found that the enrollee was admitted to the acute care hospital for coronavirus and respiratory failure. His hospital course was complicated by bradycardia, electrolytes imbalance, and a urinary tract infection. He 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 he requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are not medically necessary 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable home ventilator.

You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says Medicare does not cover ventilators for the requested use.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 requested item. Our physician reviewer found that you have a listed diagnosis of COPD, but there are no pulmonary function tests for confirmation. Mild carbon dioxide (CO2) retention is found on arterial blood gases (ABGs) testing during acute illness. You did well with BiPAP in the hospital. Medicare does not cover a ventilator when used as BiPAP, and BiPAP has not been tried and failed at home. Therefore, a home ventilator is not medically
necessary at this time. 

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 requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 prothrombin variant analysis for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this test is considered screening and is not a covered service.
The Plan must follow Medicare rules. The rules say that F2 gene testing is only covered for evaluation for venous thromboembolism. The listed diagnosis in this case is "Deficiency of other specified B group vitamins." The requested testing is only covered for venous thromboembolism. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve F2 prothrombin variant analysis for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total electric hospital bed (E0265).
You asked the Plan to pre-approve the hospital bed. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the requested total electric hospital bed is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve total electric hospital bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) machine.
You asked the Plan to pre-approve a CPAP machine. You say that you feel this item is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a new CPAP machine.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.
The file shows that the enrollee has a CPAP machine. The enrollee's current CPAP machine serves the same purpose as the requested CPAP machine. Review of the file does not support that the enrollee's current machine is broken beyond repair, lost, or stolen. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) machine
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. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care.
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 physician reviewer found that you were admitted to the acute hospital for fever and pneumonia. Intubation was required due to a decline in your respiratory status. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are 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 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: 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 to increase his functional level. The Plan denied your request. The Plan says the enrollee is unable to tolerate intensive rehabilitation due to fatigue and hypotension.
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 physician reviewer found
that the enrollee was admitted to the acute care hospital for metabolic encephalopathy. His medical problems
are stable. There is not a reasonable expectation that he will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in whirlpool tub.
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 covered.
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 walk-in whirlpool tub
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a transcatheter placement provided on May
6, 2021.

You asked the Plan to waive the copayment for a transcatheter placement. You say that you disagree with the
charges because you keep receiving bills for a $50 copayment. 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 $295
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities.

You have been asked to pay a $295 copayment for a transcatheter placement. A transcatheter placement falls
within the outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers 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 transcatheter placement provided on May 6,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 covered.
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 treat with insulin. 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 Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87541, 87581, 87640 and 87798) provided on January 12, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory however, the submitted documentation indicates that the specimen was obtained in an Assisted Living Facility on POS 13.
The Plan must follow Medicare rules. Medicare rules say that the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory place of service code while the records suggest that the member's face-to-face evaluation was rendered in an assisted living setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87541, 87581, 87640 and 87798) provided on January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty, multiple braking system, variable wheel resistance walker (E0147).
You asked the Plan to pre-approve a heavy duty, multiple braking system, variable wheel resistance walker (E0147). You say that you need a walker to get around. The Plan denied your request. The Plan says that you were already provided a heavy duty walker.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no case can be less than five years. You received a a heavy duty, multiple braking system, variable wheel
resistance walker on July 10, 2019, which is less than five years ago. Therefore, we decided that the Plan does not have to pre-approve a heavy duty, multiple braking system, variable wheel resistance walker (E0147).
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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says criteria for admission to an LTACH are not met. LTACHs are licensed to provide the same level of care as a short-term acute care hospital. There is no advantage to transferring from an acute can hospital to an LTACH at this time. There is no expectation that the requested transfer would provide a clinical advantage.
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 they are 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.