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 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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: 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 SNF services. You say that you are ready for discharge but are not able to go home because of your condition. The Plan denied your request. The Plan says that your request does not show you have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.  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 your 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.
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 these services are medically necessary. The Plan denied your request. The Plan says that your medical and rehabilitation needs are not complex and can be safely rendered at a lower level of care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical management of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after December 8, 2021.  You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the member appears to have reached the maximum benefit from daily skilled therapy and has reached a level of progress no longer requiring daily skilled therapy.  The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.  We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before December 8, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after December 8, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: 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 SNF services. You say that you would like to be admitted so your heart can get better, and you can take care of yourself. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting.  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 your 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.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you no longer require skilled services on a daily basis and the continuation of SNF is 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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued 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 continued skilled nursing facility (SNF) 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 for the enrollee.  You asked the Plan to pre-approve IRF care. You say that an IRF stay will assist the member returning to prior level of function. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.  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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for metabolic encephalopathy, rhabdomyolysis and acute kidney injury after an assault, sepsis and pneumonia. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a cane for the visually impaired (A9270).  You asked the Plan to pre-approve the cane. You say that the cane is medically necessary. The Plan denied your request. The Plan says this type of cane is considered a self-help item and is not primarily medical in nature.  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 cane for the visually impaired (A9270).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric services.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there are no medical issues that require treatment at this level of care.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided it is not expected that you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behavior. You were cooperative and compliant with treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. The health plan's denial of continued inpatient psychiatric services appears appropriate.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Synvisc-One injections (J7325).  You asked the Plan to pre-approve Synvisc-One. You say that the injections are medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that the injections are covered when the clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee.   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 Synvisc-One. Our reviewer says that the injections are not medically necessary. Our physician reviewer found coverage criteria is not met since the clinical diagnosis is not supported by radiologic evidence of osteoarthritis of the knee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One injections (J7325).
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the drugs or medicaments dispensed in the office (D9360), provided on January 13, 2021 and Periodontal maintenance (D4910), provided on June 16, 2021.  You asked the Plan to pay for the drugs and periodontal maintenance. You say that the services should be covered. The Plan denied your request. The Plan says that you exceeded the plans allowed frequency.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has failed to forward evidence to support the denial of CPT codes D9360 and D4910. The Plan has not submitted an appeal, claims or an explanation of benefits for multiple services referenced in the file. There is no evidence in the records submitted that the member has exhausted the frequency limitation for periodontal maintenance. Of note, the Plan indicates that the out-of-network denial has been waived, but there is no evidence that CPT code D9360 has been paid by the Plan. It is the burden of the Health Plan to substantiate their denial with evidence. These denials have not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the drugs or medicaments dispensed in the office (D9360), provided on January 13, 2021 and Periodontal maintenance (D4910), provided on June 16, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Volara sytem (high-frequency oscillation lung expansion)  You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show bronchiectasis, cystic fibrosis, or a neuromuscular disease.  The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.   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 system. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found this device has not been shown to be efficacious in the treatment of chronic obstructive pulmonary disease.  It combines airflow oscillation, nebulization, and positive end expiratory pressure for lung expansion. It is not the same as a chest wall oscillation device for airway clearance. There is no diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease, and therefore does not meet criteria for a chest wall oscillation device.  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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Volara sytem (high-frequency oscillation lung expansion)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided with a previously approved laminectomy and spinal fusion.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee will have drains in place and require intravenous drugs following this surgery which will require at least a three-day hospital stay. The Plan denied your request. The Plan says the laminectomy and fusion are approved as outpatient services, but the requested inpatient admission is not medically necessary for this procedure in this case.  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 payment are met in this case. Our physician reviewer found that the procedure in this case is not designated as an inpatient service. The documentation provided does not show that the enrollee has any comorbidities which would require an inpatient procedure. The procedure can be performed as outpatient observation status and may be converted to inpatient if there is a complication during or following the procedure which would warrant an inpatient stay. This review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expects that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.  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 to be provided with a previously approved laminectomy and spinal fusion.