Persius/hicric huggingface dataset:
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 the enrollee needs therapy in a SNF so that he can go home and do activities of daily living safely. The Plan denied your request. The Plan says the enrollee has not had a change in function that needs daily skilled therapy services in an inpatient SNF. The Plan says that there are no daily skilled nursing needs. The Plan says that the enrollee's need can be met at a lower 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 does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of 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 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten additional physical therapy (PT) visits (97110).
You asked the Plan to pre-approve additional PT. You say that additional therapy is medically necessary, and the enrollee's progress is slow due to age. These services help keep the enrollee functional and able to perform their duties at work and at home. The Plan denied your request. The Plan says there is no evidence that ongoing skilled physical therapy will result in the practical improvement of the enrollee's level of function within a reasonable and predictable period of time. There is no indication of a modification of the current treatment plan or goals. The enrollee is not showing any improvement in leg strength or spinal range of motion. There has been enough time with the previous visits to transition to a home exercise program. Ten additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 
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 PT. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found in this case, the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapies are not an appropriate duration and frequency for treatment of the enrollee's medical condition, and therefore 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 additional PT have not been met. Therefore, we decided that the Plan does not have to pre-approve ten additional physical therapy (PT) visits (97110).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional trips. You say that you have dialysis appointments every week. The Plan denied your request. The Plan says over 42 one-way trips are denied.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 42 one-way trips per year.
We looked at your request, the records in the case file, and the rules. The file shows that 42 trips have been used this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from October 7, 2020, to November 2, 2020.
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your request. The Plan says it is not appropriate to combine these stays.
The Plan must follow Medicare rules. Medicare rules say that when a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital on the same day for symptoms related to, or for evaluation and management of, the prior stay's medical condition, hospitals shall adjust the original claim generated by the original stay by combining the original and subsequent stay onto a single claim. We looked at the file and Medicare rules. The records show that the enrollee was discharged on October 22, 2020, and readmitted on October 23, 2020. As this was not the same day, the two stays should not be combined into a single claim/ Based on this information, we decided that Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided from October 7, 2020, to November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions (D7210 x2).
You asked the Plan to pre-approve extractions. You say that the services are necessary. The Plan denied your request. The Plan says the services at issue are not covered unless they are performed by a participating general dentist. Dental services performed by an oral surgeon are not covered.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extractions have not been met. Specifically, the services at issue are not covered unless they are performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve extractions (D7210 x2).
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the thorax (low 
dose for lung cancer screening) for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no physical exam results showing why this study is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found there is a history of a 
prior low dose lung CT dated 8/11/20 which showed abnormal ground glass opacities. This abnormality 
qualifies as an indication for followup CT however a low dose CT is not intended to serve as a diagnostic 
follow-up for a prior abnormal CT. A conventional CT of the chest would be appropriate. Also, the enrollee is 
listed as a former smoker having quit ten years ago, but the smoking history is incomplete as to the number of 
the pack years and duration, both of which must meet CMS criteria.  
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the thorax (low dose for lung cancer screening) 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 the records provided support the need for care in an
IRF. The Plan denied your request. The Plan says the records show it is not reasonable to expect the enrollee to
fully benefit from the intensity of services of an IRF. The Plan says that the enrollee can safely receive the
services needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found 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
was admitted for dizziness and was diagnosed with stroke. The enrollee's medical problems are stable. There
are no complex nursing or rehabilitation needs. 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 a 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips.
You asked the Plan to pre-approve additional transportation trips. You say that you need transportation to your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional transportation trips.
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 help with pain management and
antibiotic administration. The Plan denied your request. The Plan says the enrollee does not have acutely
complex medical needs and does not require supervision by a rehabilitation physician.
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 surgical repair of a pathologic femur fracture. Her
medical problems are stable. She does not require treatment by multiple therapies in 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care.
Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation. The elements of the coverage rule are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing provided on May 19, 2021. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing 
was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not 
appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug 
testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided 
on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medication-assisted treatment to be provided by an
OON provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are innetwork
providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan has agreed to pre-approve one month
with the requested provider to give time to transition to a participating provider. We found no exception that
would require the Plan to pre-approve additional OON services. Therefore, we decided that the Plan does not
have to pre-approve medication-assisted treatment to be provided by an OON provider
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 records provided support the need for care in an
IRF. You say that the enrollee weighs more than 500 pounds and that skilled nursing facilities will not accept
the enrollee. The Plan denied your request. The Plan says the enrollee's records do not show that the enrollee
has a need for an intensive program with a team of health care professionals and doctors that specialize in
complex medical needs as well as rehabilitation.
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
was admitted for left foot pain and flare of gout. The enrollee's medical problems are stable. There are no
complex nursing or rehabilitation needs. 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 a intensive, multi-disciplinary rehabilitation program.
There is not a reasonable expectation that this patient 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 6, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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. Cardiovascular risk assessment panels are only covered for certain indications. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Gammaplex injection provided June 5, 2021 to June 26, 
2021. 
 
You asked the Plan to pay for the Gammaplex injection. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Gammaplex injections are only covered for certain 
indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Gammaplex injection. Our reviewer says 
that the documentation does not support that the services rendered were medically reasonable or necessary. Our 
physician reviewer found the enrollee has polyneuropathy, polyarthropthy, selective deficiency of 
immunoglobulin, and abnormal immunological findings in specimens. The provided documentation did not 
clearly show evidence of IgM deficiency or other progressive condition which might warrant this treatment. 
There were no recent physician progress notes with examination and history to determine eligibility for this 
treatment. Therefore, the enrollee did not meet criteria for the services rendered.  
 
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 Gammaplex injection have not been met. Therefore, we decided that the 
Plan does not have to pay for the Gammaplex injection provided June 5, 2021 to June 26, 2021.