Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the new patient outpatient office visit (99203) and established patient outpatient office visit (99213).

You asked the Plan to pre-approve the office visits.. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve the new patient outpatient office visit (99203) and established patient outpatient office visit (99213).
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 you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met 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 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 service is medically necessary. The Plan denied your request. The Plan says the service is not 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 medical problems are stable and 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. 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. Specifically, medically necessary can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 you are receiving acute hospital care, and acute care services have not been denied. 
The documentation does not support that you require services at the LTACH that are not available at the acute 
care hospital where you are currently receiving care. The documentation does not support that an additional 25 
days of hospitalization are reasonably expected for you. 

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 an inpatient mental health admission.
You asked the Plan to pre-approve inpatient mental health admission. You say that the inpatient mental health admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the intensity of treatment and the relative freedom of movement afforded to the enrollee is inconsistent with an acute inpatient mental health treatment setting. The Plan also says that the requested admission is not medically necessary.
Our physician reviewer found that based on the provided documentation, 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 as you did not have dangerousness to self or others, perceptual disturbance including auditory or visual hallucinations. The health plan's denial of inpatient psychiatric services appears appropriate. The reviewer found that you did not appear to require inpatient mental health treatment as you were not a danger to yourself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis. The reviewer found that you were treated under an individualized treatment plan found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided, the requested admission does not meet the criteria for acute inpatient mental health treatment as you were not shown to be a danger to yourself or others but was without agitation or aggression and without perceptual disturbance including auditory or visual hallucinations. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health admission have not been met. Specifically, the file shows that the requested care can be provided in a less restrictive setting. Therefore, we decided that the Plan does not have to pre-approve an inpatient mental health admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compression device to be provided by an
out-of-network (OON) provider.
You asked the Plan to pre-approve the pneumatic compression device. You say that the services should be
covered. The Plan denied your request. The Plan says services were available from an in network provider.
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. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency transportation (A0100).
You asked the Plan to pre-approve non-emergency transportation. You say that you need transportation to your appointment. The Plan denied your request. The Plan says transportation services are not covered by the Plan.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of non-emergency transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency transportation (A0100).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Retacrit. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a history of anemia and chronic kidney disease. A laboratory data from October 7, 2021 shows a serum ferritin level of 62 ng/mL and an iron saturation of 18.2%. Based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the enrollee meets Medicare criteria for medically reasonable and necessary for the Retacrit. The enrollee's ferritin level is less than 100 ng/mL and the enrollee's iron saturation is less than 20% and there is no documentation the enrollee is receiving iron replacement therapy. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection (87633) provided on April 1, 2021.
You asked the Plan to pay for the infectious agent detection. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says Multiplex PCR respiratory viral panels
of 6 or more pathogens are non-covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 87633 is infectious agent detection by nucleic acid (DNA
or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and
multiplex amplified probe technique, multiple types or subtypes, 12-25 targets.
We find that CPT code 87633 is not supported in the record. Specifically, panels with greater than 5 respiratory
pathogens in the Part B outpatient setting are not covered as they are not considered to be medically necessary.
Based on this information, we decided that Medicare rules for coverage of the infectious agent detection have
not been met. Therefore, we decided that the Plan does not have to pay for infectious agent detection (87633)
provided on April 1, 2021.
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 enrollee has advanced arthritis with increased pain. The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is correct, because there is no documentation to support an expectation that the enrollee will require a greater than 2-midnight stay and if the enrollee experiences peri- or post-operative complications reconsideration for inpatient level of care can be given.
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 coverage are met in this case. Our physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. There is no documentation provided to support an expectation that the enrollee will require a greater than 2-midnight hospital stay. 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: 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 not 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 based on review of the available records, you do not meet criteria for an IRF admission. There is no documentation of nursing needs. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. While you may benefit from physical therapy, and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Your rehabilitation needs can be met at a less intense and alternate level of setting such as in a Skilled Nursing Facility. 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 need physical therapy and occupational therapy to become strong and at baseline level so you can go home safely. You also say that the requested services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 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 you do not have complex nursing or rehabilitation needs. The reviewer found that
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The reviewer found there is no documented need for a intensive, multi-disciplinary rehabilitation program. The reviewer found there is not a reasonable expectation that you would 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. Specifically, the file shows that there is not a reasonable expectation that you would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Unfavorable

We decided that the Plan does not have to pre-approve the home eye monitoring services.
You asked the Plan to pre-approve the home eye monitoring services. You say that you have seen several specialists and the best care was monitoring your eyes daily with the Notal Vision by 4C Home. You say that this will keep track of your retina that has a hole in it and in return let the provider know if it's progressing or regressing. The Plan denied your request. The Plan says there is not enough medical proof that shows the safety or success of the visual field assessment when used for this reason. The Plan says that this falls under the class of experimental and unproven and is not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the visual field assessment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided records do not indicate why other safe and effective methods of monitoring are not at least as beneficial as the requested service. Our reviewer says that the provided records are insufficient to determine the medical necessity and reasonableness, as defined by Medicare rules and the elements of the coverage rules are not satisfied.
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 visual field assessment have not been met. Therefore, we decided that the Plan does not have to pre-approve the home eye monitoring 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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 medical conditions are stable and 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 a 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a history of hemolytic anemia related to hereditary spherocytosis. Based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the requested use of Aranesp is Food and Drug Administration-approved for the enrollee's diagnosis. The use of Aranesp for hemolytic anemia due to hereditary spherocytosis is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.