Persius/hicric huggingface dataset:
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a 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 admission to a LTACH is not medically necessary. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the items are necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on July 7, 2020. You asked the Plan to pay for the pathology services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the pathology services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for pathology services provided on July 7, 2020.
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 disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee has a past medical history of metastatic prostate cancer with thoracic vertebral compression fractures who is living at home with increasing weakness. His medical problems are stable. There are no complex nursing or rehabilitation needs. He does 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. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 the enrollee was admitted to the current acute care hospital with abscess to the coccyx and sepsis. The enrollee was treated with antibiotics and debridement. A computerized tomography (CT) showed evidence of bony involvement. The sepsis resolved and antibiotics and basic wound care continued. The documentation does not support that the enrollee requires services at the LTACH that are not already available at the current facility. The documentation does not support that the enrollee requires services at the LTACH that are not available at the health care setting being offered by the health plan. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 the medical records do not show enrollee requires skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the member needs the inpatient rehab that a skilled
nursing facility will not be able to assist with the recovery. The Plan denied your request. The Plan says that the
enrollee can safely receive the services needed 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 peripheral vascular
disease and had a right below the knee amputation. 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
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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF System.
You asked the Plan to pre-approve a CardioMEMS HF System. 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. 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 a CardioMEMS HF System. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this device. It is not clear that the CardioMEMS device is medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMS HF System have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF System.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional home health visits for physical therapy.
You asked the Plan to pre-approve 4 home health visits. You say that your physician feels a need for continued physical therapy. The Plan denied your request. The Plan says additional services are not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 4 home health visits. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found that the documentation does not support that 4 additional home health visits for physical therapy are medically reasonable and necessary for the enrollee at this time. The records do not show that skilled nursing or skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional home health visits for physical therapy. Your complaint about receiving erroneous or incomplete information about the appeals process is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of a portable x-ray (R0070).

You asked the Plan to pay for the transportation of a portable x-ray. You say that you would like
reconsideration because this service was medically necessary. The Plan denied your request. The Plan says
Medicare rules for payment of this claim has not been met.

The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the
transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the transportation of a portable x-ray have not been met. Specifically, this claim was billed with
place of service code 31, indicating that the member is in a Part A covered SNF stay. This service is not
separately billable to Medicare Part B when the member is in a Part A covered stay. Therefore, we decided that
the Plan does not have to pay for the transportation of a portable x-ray (R0070).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulmonary panel provided on July 17, 2020.
You asked the Plan to pay for the pulmonary panel. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says a panel constitutes a single procedural service,
so one HCPCS codes must be submitted for the panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, the pulmonary panel, was requested solely for screening purposes. Medicare
does not cover this test solely for screening purposes. Additionally, the documentation submitted does not
include medical records to verify if Medicare coverage criteria have been met. Therefore, we decided that the
Plan does not have to pay for the pulmonary panel provided on July 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the specialized chair (CPT code E1399).
You asked the Plan to pre-approve the specialized chair. You say that the chair is necessary. The Plan denied your request. The Plan says the chair is not approved.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Very little clinical information was received about your illness. Your diagnosis is general symptoms and signs. Additional information was requested but not received. Therefore, we decided that the Plan does not have to pre-approve the specialized chair (CPT code E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve assured comfort signature series hi-low adjustable queen size bed frame, headboard, side rails, transfer mattress, side panels and footboard.

You asked the Plan to pre-approve assured comfort signature series hi-low adjustable queen size bed frame, headboard, side rails, transfer mattress, side panels and footboard. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not covered.

The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary for certain indications. The rules also say that for equipment to be covered, it must primarily serve a medical purpose. 

We looked at the file and Medicare rules. Review of the file shows that the bed board 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. The requested specific bed frame, mattress, headboard, footboard, and side panels appear to be custom and not primarily serving a medical purpose. There was no information provided as to why a hospital bed cannot meet the enrollee's needs.

Based on this information, we decided that Medicare rules for coverage of assured comfort signature series hi-low adjustable queen size bed frame, headboard, side rails, transfer mattress, side panels and footboard have not been met. Therefore, we decided that the Plan does not have to pre-approve assured comfort signature series hi-low adjustable queen size bed frame, headboard, side rails, transfer mattress, side panels and footboard.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has pain related to right knee osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Gel-One is not reasonable o 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 pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and sacroilitis. The requested RFA of the lateral sacral branches is considered experimental/investigational in nature due to wide variation of efficacy reported in medical literature. The services are 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 pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.
Local Coverage Determination (LCD) L33622 referenced by the Plan is not binding for the services at issue and was not used in the MAXIMUS determination.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the full hereditary cancer panel provided on July 28, 2020. You asked the Plan to pay for the full hereditary cancer panel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the full hereditary cancer panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not include any medical records to confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the full hereditary cancer panel provided on July 28, 2020.