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

We decided that the Plan does not have to pre-approve 8 additional physical therapy visits.

You asked the Plan to pre-approve the 8 additional physical therapy visits. You say that the low back condition and the left-hand, arm, and neck are separate condition and should be treated separately under separate authorization. You say that treatment is needed for both of those conditions. The Plan denied your request. The Plan says the physical therapy visits which remain in dispute are not medically necessary. The Plan says that the enrollee has not made significant progress and does not appear to have potential to improve.

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 the 8 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based on the available records the enrollee appears to have plateaued with therapy. Further therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status.

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 8 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy 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 IRF care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for IRF care have 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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, 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. Finally, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a face bone graft (21210) and reconstruction of the jaw (21248).

You asked the Plan to pre-approve the face bone graft and reconstruction of the jaw. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are dental in nature and are not covered.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a face bone graft (21210) and reconstruction of the jaw (21248).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging.

You asked the Plan to pre-approve myocardial perfusion imaging. You say that the enrollee has a history of abnormal cardiac rhythm and is not experiencing chest pain and dyspnea on exertion. You say that the enrollee has an unclear ECG tracing that indicates there may have been damage to the heart. You say that myocardial perfusion imaging is needed to better evaluate the enrollee's cardiac status. The Plan denied your request. The Plan says that the enrollee does not have any indications required for coverage of the requested imaging.

The Plan must follow Medicare rules. Medicare rules say that cardiovascular nuclear imaging is indicated for the diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused by drugs, bundle branch block, or left ventricular hypertrophy.

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 myocardial perfusion imaging. Our reviewer says that myocardial perfusion imaging is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has at least an intermediate global risk for coronary artery disease based on hyperlipidemia, hypertension and advanced age. She has symptoms of dyspnea on exertion, so some type of ischemic testing is warranted. In addition, she has poor R wave progression on EKG, suggesting a possible old MI and more importantly a "fragmented QRS" which is a more sensitive determinant of possible prior MI (1). The baseline EKG is abnormal and the QRS fragmentation (a type of interventricular conduction delay/bundle branch block) will likely decrease the specificity of any EKG only stress test and make it uninterpretable for ischemia. Therefore, in this instance use of an imaging modality (nuclear imaging) in addition to EKG stress testing will add needed specificity and interpretability to the stress testing. This meets the rules for its utilization in this specific clinical circumstance.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have been met. Therefore, we decided that the Plan has to pre-approve myocardial perfusion imaging.

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 admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says continued care could be better provided in an outpatient, skilled nursing facility or long term care facility setting.

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 were admitted for rib fracture 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve supplies for a CGM (K0553).

You asked the Plan to pre-approve supplies for a CGM. You say that the requested items are medically necessary. The Plan denied your request. The Plan says rules for pre-approval have not been 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 perform blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of supplies for a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve supplies for a CGM (K0553).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for SNF care have 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 while there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and 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 the skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3D rendering with Interpretation and Reporting of Magnetic Resonance Imaging (MRI) of the pelvis (76377).

You asked the Plan to pre-approve a 3D rendering. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the clinical information provided does not support the requested imaging.

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 3D rendering. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records provided do not meet the requirements for Medicare coverage. Sufficient clinical data are not available for 3D rendering without a PIRADS (Prostate Imaging Reporting and Data System) 4 or 5 lesion on MRI. As this is not noted, this request is not supported by current literature.

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 3D rendering have not been met. Therefore, we decided that the Plan does not have to pre-approve 3D rendering with Interpretation and Reporting of Magnetic Resonance Imaging (MRI) of the pelvis (76377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460).

You asked the Plan to pay for the pulp vitality tests. You say that you were under the impression that everything would be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 pay for the pulp vitality tests (D0460).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Minuteman procedure (22612).

You asked the Plan to pre-approve the Minuteman procedure. You say that this is the most appropriate treatment for the enrollee's condition. The Plan denied your request. The Plan says the surgery requested is not considered standard of care and is experimental/investigational.

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 Minuteman procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Minuteman procedure remains experimental for the treatment of low back pain. The surgical procedure has not been clearly shown to be safe and effective in the literature. More research is needed to show safety and efficacy of the Minuteman procedure.

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 Minuteman procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Minuteman procedure (22612).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient hospital care.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit has been exhausted.

The Plan must follow Medicare rules. The rules say that no more than 90 consecutive days in a benefit period can be covered for inpatient hospital services.

The file shows that 90 days of inpatient service have been exhausted. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not tried an oral bisphosphonate, and there is no clinical reason to avoid treatment with an oral bisphosphonate.

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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of oral bisphosphonates before they will approve the requested drug. Our reviewer found that the enrollee has not tried and failed the required drug(s). Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
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 a skilled nursing facility is not the appropriate level of care at this time, due to the enrollee's complexity of care needs and the frequency of complications he has suffered. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.

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 there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 a portable oxygen concentrator.

You asked the Plan to pre-approve the oxygen. You say that this is medically necessary. The Plan denied your request. The Plan says this is being requested for use outside of the home.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 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 oxygen. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you have chronic obstructive pulmonary disease (COPD) and require supplemental oxygen at night and with activity. You have a stationary concentrator, and portable E tanks that are provided through the Veteran's Administration (VA) system. You are requesting this portable concentrator for ease of travel outside of home. Medicare covers portable oxygen systems for use within the home,but does not specify which system is to be used. As you already have portable oxygen, this request is a duplicate. A portable oxygen concentrator when used for travel is a convenience item and is not covered. This is 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 the oxygen have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee's complex medical needs require ongoing acute care. The Plan denied your request. The Plan says the LTACH would not provide any additional services.

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 the enrollee appears to be more stable but requires additional short-term acute care services to help further stabilize the enrollee prior to transfer which can safely be received at the current facility. The enrollee does not require services at the LTACH that are not already available at the current 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 the LTACH services.