Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided necessitating admission to a 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.

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 Freestyle Libre therapeutic continuous glucose monitor.

You asked the Plan to pre-approve continuous glucose monitor. You say that this should be covered by the Plan. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee does not check the glucose level 4 or more times per day and does not inject insulin 3 or more times per day.

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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ketamine infusions.

You asked the Plan to pre-approve ketamine infusions. You say that without these infusions, your quality of life would take a real hit. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because infusions of ketamine for treatment of your condition is not an accepted standard of medical practice.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 ketamine infusions. Our reviewer says that you do not meet the Medicare criteria for the requested infusions. Our physician reviewer found the requested use of ketamine infusions is not Food & Drug Administration (FDA) approved for your diagnosis. This use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. This would be an experimental/investigational procedure. There are other evidence-based therapies available to you. This request 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 ketamine infusions have not been met. Therefore, we decided that the Plan does not have to pre-approve ketamine infusions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the OON medical services. You say that the enrollee does not want to go the surgical route and the requested doctor may be able to help her without surgery. The Plan denied your request. The Plan says the participating provider they have referred the enrollee to is able to provide the services need, has appointments available in a reasonable amount of time, and is within a reasonable distance of the enrollee's home.

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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network office visits.

You asked the Plan to pre-approve out-of-network office visits. You say that the doctor is the best in anterior hip replacements. You say that you will get outstanding treatment with this doctor. The Plan denied your request. The Plan says the request for an out-of-network provider is not covered.

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 out-of-network office visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy ordered by a chiropractor.

You asked the Plan to pre-approve the physical therapy ordered by a chiropractor. You say that the chiropractic care was accidentally requested under the chiropractor and should have been requested under a different provider. The Plan denied your request. The Plan says chiropractic services extend only to treatment by means of manual manipulation of the spine to correct a subluxation. The Plan says that all other services furnished or ordered by chiropractors are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve physical therapy ordered by a chiropractor.

Please note, our determination pertains to the authorization as it was requested and the Plan's determination regarding that authorization request. If you wish to make a new authorization request, with orders from a different provider, you would make that request through the Plan directly.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the leg joint.

You asked the Plan to pre-approve the MRI. You say that the requested MRI is medically necessary. The Plan denied your request. The Plan says the clinician's office did not provide documentation showing that the enrollee meets the guidelines for the requested MRI, which does not appear to be medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found there is no clinical rational for the requested MRI of the right hip. On exam, the enrollee has hip tenderness to palpation. There is no documentation of the response to medical therapy or physical therapy.

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the leg joint.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart.

You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says a CT scan is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 CT scan. Our reviewer says that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found that based on current guidelines, CT calcium scanning can be utilized when risk is borderline or intermediate as a risk modifier to further refine the need for statin therapy. In this case, however, the enrollee's 10-year cardiovascular risk is already high, and statin therapy is indicated based on his high calculated 10-year CV risk. Therefore, CT calcium scoring is not medically necessary per CMS rules.

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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic dental consultation.

You asked the Plan to pre-approve a diagnostic dental consultation. 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 a covered benefit.

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 diagnostic dental consultation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low-level cold laser therapy.

You asked the Plan to pre-approve laser therapy. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any related accessories is not reasonable and necessary. 

We looked at the file and Medicare rules. Per the applicable NCD, the requested laser therapy is not medically reasonable and necessary, and therefore is non-covered. Based on this information, we decided that Medicare rules for coverage of laser therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve low-level cold laser therapy.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approve the scan of the abdomen. We decided that the Plan does not have to pre-approve the scan of the pelvis.

You asked the Plan to pre-approve the scan of the abdomen and pelvis. You say that this is medically necessary. The Plan says that there is no clear indication for the scan noted in the records.

We decided that the Plan has to pre-approve the scan of the abdomen.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 for CT scan of the abdomen. Our reviewer says that the requested scan is medically reasonable or necessary. Our physician reviewer found that the enrollee is obese with BMI of 33. More likely than not the artifact noted on the Lexiscan is related to body habitus. However, the idea of excluding a upper abdominal mass as the explanation is reasonable. For these reasons a CT of the abdomen with contrast infusion will answer the clinical question.

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 scan of the abdomen have been met. Therefore, we decided that the Plan has to pre-approve the scan of the abdomen.

We also decided that the Plan does not have to pre-approve the scan of the pelvis.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 for CT scan of the pelvis. Our reviewer says that the requested scan is not medically reasonable or necessary.

Our physician reviewer found that there is no pelvic symptom, so the request to include the pelvis on the exam has not been established. The CT of the pelvis is not 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 the scan of the pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve the scan of the pelvis.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit provided to the enrollee.

You asked the Plan to pre-approve the visit. You say that this should be paid for. The Plan denied your request. The Plan says the services were not referred by a network provider or rendered in a participating facility.

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 an office visit provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with extractions (D7311).

You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied your request. The Plan says alveoloplasty in conjunction with extractions is not listed as a covered service.

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 an alveoloplasty in conjunction with extractions (D7311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) is non-covered. 

We looked at the file and Medicare rules. The requested item is a power seat elevation feature. This item is not covered by Medicare because it does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for oxygen supplies with an out-of-network provider.

You asked the Plan to pre-approve the referral. You say that this provider has been providing your oxygen. The Plan denied your request. The Plan says there is no urgent or emergent medical condition.

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 referral for oxygen supplies with an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve these services. You say that the enrollee is unable to walk and is working on cognitive ability. The Plan denied your request. The Plan says the 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 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF with weakness and confusion after a stroke. He received oral medications and had stable vital signs. He received physical and occupational therapy in the SNF and needs assistance with functional mobility, including walking to 120 feet with a rolling walker. He needs varied assistance with activities of daily living. He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.

You asked the Plan to pre-approve Insertion 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).

You say that the enrollee needs this procedure. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and 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 Insertion 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).

Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show the safety and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Insertion 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 spinal surgery.