Persius/hicric huggingface dataset:
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 the SNF services. You say that you have not been given enough time to recover. The Plan denied your request. The Plan says the enrollee's needs are custodial and daily skilled services are not needed. The Plan says that the enrollee's needs can be met at a lower level of 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no complex wound care, IV medications or other skilled nursing need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on 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 the 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be received in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.

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 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 hip pain, without fracture, 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yervoy.

You asked the Plan to pre-approve Yervoy. 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 a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Yervoy. Our reviewer says that the medication is not medically necessary. Our physician reviewer found as not stage III because nodes were not sampled and no in transit metastasis adjuvant yervoy, as adjuvant opdivo, are denied. No adjuvant therapy is indicated. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF services.

You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the records do not support the SNF services you are requesting.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.

We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (K0861) and related accessories.

You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options and related accessories. You say that the enrollee qualifies for a Group 3 power wheelchair with multiple power options because the enrollee is unable to perform functional weight shift due to decreased arm strength and needs the power tilt and recline features. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who meet coverage criteria for a power tilt and recline seating system.

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 Group 3 power wheelchair with multiple power options and related accessories. Our reviewer says that a Group 3 power wheelchair (K0861) is not medically necessary per Medicare rules. Our physician reviewer found that the enrollee has a personal mobility deficit that impairs participation in mobility-related activities of daily living (MRADLs) and is unable to use cane/walker due to poor balance or a manual wheelchair due to unable to propel effectively. The enrollee has a neurologic condition that would require a Group 3 powered wheelchair. However, the power seating system is not medically necessary. The enrollee is not at high risk for development of a pressure ulcer, not using intermittent catheterization for bladder management, nor needs the power seating system to manage increased tone or spasticity. As the Group 3 power wheelchair with power seating system is not medically necessary, the additional requested accessories are 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 a Group 3 power wheelchair with multiple power options have not been met. Related accessories are not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (K0861) and related accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (64491).

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the allowed units for this service were exceeded.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 64491 is 1. You billed 2 units of this code, exceeding the MUE. 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 pay for the services (64491).
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. You say that the enrollee is at an acute care facility and ready for
discharge, but waiting for approval to be admitted to an IRF. The Plan denied your request. The Plan says
criteria for admission to the Acute Inpatient Rehabilitation setting 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.

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 enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer
found that the enrollee's current medical condition does not require intensive physician or nursing supervision
in an IRF. Our physician reviewer also found that the enrollee may benefit from additional physical and
occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.

You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says this clinical value and effectiveness of this device has not been demonstrated in peer-reviewed literature.

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 Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy. 

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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the services provided were medically necessary. The Plan denied your request. The Plan says there is no evidence prescribing physician ever saw the member.

The Plan follows Medicare rules. Medicare rules say that for the selected knee orthosis, knee instability must be documented by examination of the beneficiary and objective description of joint laxity.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the knee orthosis and suspension sleeve. Our reviewer says that the services were not medically necessary and reasonable. Our physician reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833) and knee sleeve (L2397).

You asked the Plan to pay for a knee brace and sleeve. You say that the items are medically necessary. The Plan denied your request. The Plan says there is insufficient documentation indicating the medical necessity of the items provided.

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 pay for a knee brace and sleeve. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity.

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 knee brace and sleeve have not been met. Specifically, there is insufficient documentation indicating the medical necessity of the items provided. Therefore, we decided that the Plan does not have to pay for a knee brace (L1833) and knee sleeve (L2397).
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 LTACH care is medically necessary as the enrollee needs long-term care. The Plan denied your request. The Plan says LTACH care 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 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 she 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 pay for the knee orthosis (L1833) and suspension sleeve (L2397).

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence that the prescribing physician ever examined the member.

The Plan follows Medicare rules. Medicare rules say that knee instability must be documented by examination of the beneficiary and objective description of joint laxity before the knee orthosis will be approved.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the knee orthosis and suspension sleeve. Our reviewer says that the items purchased were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care for the enrollee.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 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 this enrollee does not require skilled nursing (SN) services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no complex wound care or other SNF level SN need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a SNF 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 SNF care for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder brace (L3960).

You asked the Plan to pay for shoulder brace. You say that the item was medically necessary. The Plan denied your request. The Plan says there is insufficient documentation indicating a medical need for the item provided.

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 pay for shoulder brace. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible physical examination of the shoulder.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shoulder brace have not been met. Specifically, there is no physical examination indicating the medical necessity of the item provided. Therefore, we decided that the Plan does not have to pay for shoulder brace (L3960).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lenses.

You asked the Plan to pay for the provided lens. You say that you have a medical condition that requires these types of lenses. The Plan denied your request. The Plan says the lenses are not a covered benefit.

The Plan must follow Medicare rules. The rules say that covered diagnoses for refractive lenses are limited to pseudophakia, aphakia, and congenital aphakia.

We looked at the file and the rules. The records do not indicate that you have a diagnosis that is indicated for coverage. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the contact lenses.