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 physical therapy is needed to regain strength and mobility. The Plan denied your request. The Plan says the criteria for this admission is not 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of hypertension, lumbar degenerative disc disease and neuropathy who is living at home with weakness and back pain after a fall. 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 the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve G-CSF (Filgrastim) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered for afebrile neutropenia.
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 the drug. Our reviewer says that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee experienced a dose-limiting neutropenic event in the setting of cisplatin and gemcitabine with a low absolute neutrophil count (ANC). This increases the risk of neutropenic fever to more than 20% and makes the use of growth factors such as the requested drug medically reasonable and 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 drug have been met. Therefore, we decided that the Plan has to pre-approve G-CSF (Filgrastim) for the enrollee.
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: 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 will benefit from acute rehabilitation to
optimize his level of functioning prior to returning home. The Plan denied your request. The Plan says the
enrollee does not meet criteria for an IRF admission, it is 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, multidisciplinary
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive dental services.
You asked the Plan to pre-approve the dental services. You say that chemotherapy has caused tooth
degeneration. The Plan denied your request. The Plan says the services are not covered under your benefit.
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.
The file shows that a dental crown, core buildup, and filling were requested. Although the Plan offers a dental
benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pre-approve comprehensive dental services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care
provided March 10, 2021, to March 31, 2021.
You asked the Plan to waive the copayment for the SNF care. You say that you were not aware you would be
charged a copayment. The Plan denied your request. The Plan says the copayment has processed correctly in
this case.
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 $0
copayment per day for days 1-20 and a $184 copayment per day for days 21-100 for skilled nursing facility
care.
You have been asked to pay a total cost share of $368 for the SNF care (2 days x $184 copayment). This
service falls within the skilled nursing facility 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 the skilled nursing facility (SNF) care provided March 10, 2021, to March 31, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says multiple attempts were made unsuccessfully to obtain updated physical and occupational therapy progress notes.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not document skilled nursing or skilled therapy needs. You are ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network pulmonary specialist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says members must use network providers to get medical care and 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 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 a referral to an out-of-network pulmonary specialist.
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 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 do 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.
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 pre-approve 6 office visits/treatments with an out of network (OON)
provider.
You asked the Plan to pre-approve the 6 OON office visits. You say that the enrollee has a very complex
neuromuscular condition that cannot be adequately evaluated other than at the OON clinic being requested. The
Plan denied your request. The Plan says the enrollee's condition can be treated with the network.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few
exceptions, enrollees must use contract providers for care.
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 6 OON office visits. Our reviewer
says that the criteria for coverage of OON care have not been met. Our physician reviewer found the Plan's
denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs
through referral to an in-network neurologist. The Plan says that there is nothing unique about the enrollee's
condition that would make it medically necessary for her to see the requested OON provider. While the
enrollee's diagnosis may not be straightforward, there is no unique circumstance presented that would warrant
the OON referral. The Plan has given the enrollee the names of other in network providers with whom they
could consult.
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 6 OON office visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve 6 office visits/treatments with an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to an LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to an LTACH does
not meet criteria.
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 that you remain on the ventilator with decreased responsiveness making yourself
unable to be weaned at this time. You continue to receive acute critical care services, and these have not been
denied. The medical record does not indicate that you require services that you are not currently receiving but
that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic device to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the necessary services may be obtained in-network.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a prosthetic device to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor and segmental pneumatic appliance from an out of network (OON) provider.

You asked the Plan to pre-approve the OON pneumatic compressor and segmental pneumatic appliance. You say that the OON provider is the only provider in your area that specializes in the Airos 8 Lymphedema pump and your doctor ordered. You say that this specific pump will provide you with better health and prevent future hospital stays. The Plan denied your request. The Plan says there are network providers within a reasonable distance of the enrollee that can provide a pneumatic compressor and segmental pneumatic appliance.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

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 OON pneumatic compressor and segmental pneumatic appliance. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not support the medical necessity of out of network care. The current request is for a particular brand of a high-level pneumatic compression pump, which is typically a pump that allows for individual calibration of each segment. There is satisfactory documentation in the record of severe lower extremity edema that might benefit from a segmented lymphatic pump. However, a segmented pump without individual calibrated segments has not yet been satisfactorily trialed and failed to help. The health plan has in network providers within a reasonable distance of the enrollee that can provide a pneumatic compressor and segmental pneumatic appliance. There are no unique features of this patient's condition that would necessitate a particular brand pump. 

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 OON pneumatic compressor and segmental pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor and segmental pneumatic appliance from an out of network (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 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 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 do 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.

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 Guardant360 testing (81479) provided on March 28, 2021.
You asked the Plan to pay for Guardant360 testing. You say that this testing is a Medicare-covered service. The Plan denied your request. The Plan says the enrollee has previously received this testing.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is covered only when the patient has not previously been tested with the Guardant360 test for the same genetic content. For a patient who has been tested previously using Guardant360 for cancer, that patient may not be tested again unless there is clinical evidence that the cancer has evolved wherein testing would be performed for a different genetic content.
We looked at the file and Medicare rules. The record shows that the enrollee has previously received Guardant360 testing. The submitted records do not include clinical evidence that the testing at issue was for different genetic content. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81479) provided on March 28, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered from March 15, 2021 to March 22, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for emergency services and an emergency is defined as when a person would believe that without immediate medical attention there would be serious jeopardy to his or her health. 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 these services. Our reviewer says that the services were not emergent in nature. Our physician reviewer found the records show that you have a history of chronic back pain due to severe spinal disease. You were informed about increase in size of the abdominal aortic aneurysm (AAA) and referred for an outpatient evaluation by vascular surgery. The notes state you did not want to go home and wanted to be admitted for further evaluation. Although the aneurysm repair was indicated, the chronic pain had not changed in the past several days. There was a reasonable outpatient plan of care in place and you chose to visit the ER instead. The records do not support that a prudent layperson would consider the services a medical emergency. The ER services were therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered from March 15, 2021 to March 22, 2021.