Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional physical therapy (PT) visits.
You asked the Plan to pre-approve 2 additional PT visits. 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 medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 2 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found you have chronic low back pain which has improved with the initial 15 physical therapy sessions. There is no documentation to support that additional physical therapy sessions are required. Additional sessions would be considered excessive in number and not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 2 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional physical therapy (PT) visits.
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 enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a seizure and pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in 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. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter (E0118).
You asked the Plan to pre-approve a knee scooter (E0118). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this is not an item that is covered by Medicare at this time.
The Plan must follow Medicare rules. The DME MAC has determined that there is not sufficient evidence to support the medical necessity of a knee scooter at this time. Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that continued inpatient skilled nursing facility care is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of continued inpatient skilled nursing facility care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says that continued inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that at the time of the admission, you required skilled rehabilitation services to improve function due to weakness and deconditioning. You did not have skilled nursing needs. As of April 15, 2021, you did not require any skilled nursing or rehabilitation services on a daily basis. You were not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. You did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care. You did not have any parental medications, complex wound care or nutrition given via a feeding tube. You received skilled care and improved; however, your function had plateaued and you did not require any further inpatient skilled rehabilitation services.
Your function was at or near your prior level of function and you could be discharged to a lower level of care for further services. As of April 15, 2021, you required custodial 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high strength lightweight wheelchair and accessories.
You asked the Plan to pre-approve a high strength lightweight wheelchair and accessories. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a high strength lightweight wheelchair (K0004) is covered when a beneficiary meets specific criteria. 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 high strength lightweight wheelchair and accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found the documentation does not support that criteria for a high strength lightweight wheelchair is made. The documentation does not support that a standard wheelchair would not be able to provide the functional support you require. 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 high strength lightweight wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a high strength lightweight wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-ofnetwork
provider.
You asked the Plan to pre-approve the physician's services to be provided by the out-of-network provider.
The Plan denied your request. The Plan says the services are not emergent or urgent and are available innetwork.
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 services. Therefore, we decided that the Plan does not have to pre-approve
physician's services to be provided by the out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer surgical procedure.
You asked the Plan to pre-approve interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). You say that the enrollee needs this procedure for pain relief. The Plan denied your request. The Plan says the procedure has not been shown to be safe and effective in long term studies.
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 interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are multiple plausible pain generators. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for spacer is not medically reasonable or 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 interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer surgical procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neuromuscular electrical stimulator to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a neuromuscular electrical stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says this is available 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 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 neuromuscular electrical stimulator 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 continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that it is felt this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage of this CGM are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or that you require frequent self-adjustment of insulin dosage based on the blood glucose testing results. The records show that the enrollee currently uses on daily long-acting insulin injection which is not adjusted based on readings. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 is in need of intensive therapies. The Plan denied your request. The Plan says criteria for the IRF level of care are 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 patient was admitted for a urinary tract infection and bladder cancer. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve therapeutic CGM. You say that it is no longer easy for the enrollee to use a regular glucose monitor. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee does not use insulin and does not test 4 times daily.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
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 IRF care is 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for aT10 compression fracture and scalp hematoma after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 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 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Ketamine infusion provided to the enrollee.
You asked the Plan to pay for this service. You say that this claim should be paid as it was approved by the ALJ. The Plan denied your request. The Plan says the case that was decided by the ALJ was a pre-service case and not included in this claim. The Plan state prior authorization for this date of service was requested and denied. This service was provided without prior authorization.
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. This treatment was provided out of network and was denied prior to treatment. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for Ketamine infusion provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for septic arthritis of the shoulder treated with surgery and antibiotics. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in 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. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialty absorptive dressings.
You asked the Plan to pre-approve these services. You say that you need the dressings for your ileostomy. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that specialty absorptive dressings are covered when used for moderately or highly exudative full thickness wounds (e.g., stage III or IV ulcers). We looked at the file and Medicare rules. The records show that you do not have a stage III or stage IV ulcer. 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 specialty absorptive dressings.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. You say that you believe this service should be approved for coverage. The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's plan.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).