Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulation (TENS) device.You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that a TENS unit is only covered under certain medical indications.  We looked at the file and Medicare rules. The documentation provided does not show that you are enrolled in an approved clinical trial. Based on this information, we decided that Medicare rules for coverage of the requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulation (TENS) device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveimage-guided radiation therapy (IGRT)-10 fractions (treatment sessions). You asked the Plan to pre-approve image-guided radiation therapy. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested 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 image-guided radiation therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Image guided radiotherapy (IGRT) is a means of using of using daily image guidance to help localize the target so as to minimize normal tissue dosing. IGRT allows accuracy of treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. IGRT images can be obtained prior to treatment on a daily basis (interfraction IGRT),and/or before and during radiation (intrafraction IGRT). Daily CT imaging or kv-kv imaging, to verify position prior to every fraction, is an integrated feature with the LINAC used for this enrollee as described in the case records. Generally, it is used when there is a need to escalate the dose and or use tight margins to adequately treat the target while sparing surrounding normal tissue. With whole brain radiation, it is not standard to use IGRT. While undeniably radiation therapy is medically necessary, there is not a need for IGRT. Therefore, the enrollee does not meet criteria for the requested 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 image-guided radiation therapy have not been met.Therefore, we decided that the Plan does not have to pre-approv eimage-guided radiation therapy (IGRT)-10 fractions (treatment sessions).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe inpatient mental health care stay provided from October 21, 2019 to October 23, 2019.You asked the Plan to waive the coinsurance forthe inpatient mental health care stay. You say that you were never informed that the hospital was out-of-network. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 50% coinsurance for inpatient mental health care at an out-of-network inpatient hospital or inpatient psychiatric facility. You have been asked to pay $1,148.60 which is 50% of the allowed amount for the inpatient mental health care stay. The allowed amount is $2,297.20. ($2,297.20 x 50% = $1,148.60). The inpatient mental health care stay falls within the "Inpatient mental health care" benefit category. The record shows that the hospital is out-of-network.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 coinsurance forthe inpatient mental health care stay provided from October 21, 2019 to October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra wide/heavy duty commode chair.
You asked the Plan to pre-approve an extra wide/heavy duty commode chair. You say that you are unable to fit
on a small commode and the rim is uncomfortable. The Plan denied your request. The Plan says that you do not
meet requirements for this item.
The Plan must follow Medicare rules. Medicare rules say that an extra wide/heavy duty commode chair
(E0168) is covered for a beneficiary who weighs 300 pounds or more.
We looked at the file and Medicare rules. The record indicates you do not weigh more than 300 pounds. Based
on this information, we decided that Medicare rules for coverage of an extra wide/heavy duty commode chair
have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra wide/heavy duty
commode chair.
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 enrollee would benefit from a transfer to an LTACH due to her high nursing needs.The Plan denied your request. The Plan says the enrollee can be treated at the current hospital.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 is currently undergoing treatment at an acute care hospital (ACH) for viral encephalitis and worsening dementia. The enrollee was intubated/extubated several times before eventually receiving a tracheotomy. Her long-term prognosis is noted to be poor. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred or discharged to a lower level of care for any ongoing long term care needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says your records show you do not require intensive rehabilitation nor an intensive team approach with frequent physician supervision. You can safely receive the services you need in other settings at a different level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not meet criteria for coverage for an IRF admission. You are generally medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient physicianwho specializes in rehabilitation three times per week or need for acute rehab nursing care. You have continued pain and are unable to do therapy. While you may benefit from continuing physical therapy and occupational therapy, there is no documented evidence showing status and participation and need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Ubrelvy tablet medication.You asked the Plan to pre-approvethis medication. You say that it is medically necessary for the enrollee to receive this medication for the treatment of chronic migraine.The Plan denied your request. The Plan says that the enrollee has a medical (MA) only policy with plan , not a Prescription Drug Plan (PDP). Therefore, coverage is limited to Medicare Part B covered drugs. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here isnot among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Ubrelvy tablet medication.Benefits for this medicationmay be available under Medicare Part D. Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea blood pressure monitor.You asked the Plan to pre-approvethe requested device. The Plandenied your request. The Plan says a blood pressure monitor is covered only for home dialysis.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to pre-approvea blood pressure monitor.
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 SNF admission. 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 Medicare pays for care in a SNF when the four factors listed above 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital with sepsis, inflamed hematocele and pneumonia. You received oral medications and IV antibiotics. You had stable vital signs. You could roll in bed with modified independence but refused therapy intervention. The documentation does not support that you require the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis, at a SNF 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 SNF 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Cosentyx Sensoready Pen for the enrollee.You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered by Part B.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approve the Cosentyx Sensoready Pen for the enrollee.Benefits for this drug may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not need to be seen by a rehab specialist 3 or more times per week, or continuous rehab nursing care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 physician reviewer found that the enrollee was on a regular diet. His metabolic panel count did not reveal significant abnormalities. He has a diagnoses of chronic anemia. He was put on antibiotics for a UTI. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. His current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however, his functional level of non-weight bearing status with documentation of fatigue in therapy, does not require or indicate that this therapy must be in an IRF with an intensive level 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for bilateral pleural effusion and chronic respiratory failure. The enrollee was transiently intubated/ventilated, but was extubated. However, it appears that the decision was made to perform a tracheotomy so that the enrollee could receive long-term pulmonary toilet and nightly CPAP. There is no evidence that the enrollee is expected to e decannulated, or that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external insulin pump (E0784).
You asked the Plan to pre-approve an external insulin pump. You say that the requested item is 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 an external infusion pump is covered when specific criteria is met. 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 an external insulin pump. Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee is noted to be a type II diabetic with a c-peptide level <110% of the lower limit of normal. It is reported that the enrollee has completed a diabetes education program. The enrollee does test his blood glucose four times a day. However, the enrollee's insulin regimen is unclear. A medication list notes Trulicity, Novolog and Lantus. The discussion notes the use of Novolog and the plan notes adjustments to Lantus. Dosages appear to be set dose, not sliding scale. As there is no evidence that the enrollee is frequently self-adjusting insulin dosages, the use of an insulin pump is not shown to be medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an external insulin pump have not been met. Therefore, we decided that the Plan does not have to pre-approve an external insulin pump (E0784).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approved estruction by neurolytic agent, 1 unit (64635) and destruction by neurolytic agent, additional 3 units (64636).You asked the Plan to pre-approve destruction by neurolytic agent, 1 unit and destruction by neurolytic agent, additional 3 units. You say that the service is necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that non-thermal RF modalities for facet joint denervation including chemical, low grade thermal energy (<80 degrees Celsius), as well as pulsed RF 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 destruction by neurolytic agent, 1 unit and destruction by neurolytic agent, additional 3 units. Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee meets the criteria for radio frequency ablation (RFA) and conventional RFA will be used. The requested procedure is 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 destruction by neurolytic agent, 1 unit and destruction by neurolytic agent, additional 3 units have been met.Therefore, we decided that the Plan has to pre-approve destruction by neurolytic agent, 1 unit (64635) and destruction by neurolytic agent, additional 3 units (64636).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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection and seat elevation system for your power wheelchair.You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says right upper limb strength and function described are adequate for the enrollee to control the approved power options using their own switches.The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Medicare rules say that an electrical connection is only covered under certain medical indications. 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 electronic connection. Our physician reviewer found that based on the medical records provided,the requested electronic connection (E2311) is not medically reasonable and necessary for the approved power functions on the wheelchair. You have documented normal strength and coordination of the right upper extremity to control the wheelchair.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 requested items have not been met.Therefore, we decided that the Plan does not have to pre-approve an electronic connection and seat elevation system for your power wheelchair.