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

We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from August 31, 2021 and forward.

You asked the Plan to pre-approve the continuation of inpatient mental health care from August 31, 2021 and forward. You say that the continuation of inpatient mental health care from August 31, 2021 and forward is medically necessary. The Plan denied your request. The Plan says the continuation of inpatient mental health care from August 31, 2021 and forward is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 continuation of inpatient mental health care from August 31, 2021 and forward. Our reviewer says that the continuation of inpatient mental health care from August 31, 2021 and forward is not medically necessary. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. I am unable to find an individualized treatment plan however the entire chart is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review of the records provided this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of August 31, 2021 and forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. 

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 continuation of inpatient mental health care from August 31, 2021 and forward have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from August 31, 2021 and forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home mechanical ventilator (E0466).
You asked the Plan to pre-approve the home mechanical ventilator. You say that you would like reconsideration because you need this device to breathe and will choke if not treated. The Plan denied your request. The Plan says you will be using the home mechanical ventilator (E0466) in a BiPAP mode.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home mechanical ventilator. Our reviewer says that a home ventilator is not medically necessary for you. There is a diagnosis of COPD, but the medical records do not provide pulmonary function tests to confirm, and there is no documentation of CO2 retention on an arterial blood gas. Our physician reviewer found there is no evidence that BiPAP has been tried and failed. The ventilator is being used as BiPAP, which is not covered by Medicare.
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 home mechanical ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home mechanical ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a custom fabricated oral splint. 
 
You asked the Plan to pre-approve a custom fabricated oral splint. You say that the requested custom fabricated 
oral splint is medically necessary. The Plan denied your request. The Plan says that the requested custom 
fabricated oral splint is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically 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 a custom fabricated oral splint. Our 
reviewer says that the requested custom fabricated oral splint is medically necessary. Our physician reviewer 
found a diagnosis of osteoarthritic changes to the TMJ due to clenching and bruxism resulting from stress and 
tension. The treatment involved is medically reasonable and necessary along with the recommended jaw 
exercises and diet recommendations given to the enrollee. The treatment does not involve dental related care. 
The documentation supports the criteria for coverage for an oral splint for treatment of the enrollee's TMJ pain. 
 
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 custom fabricated oral splint have been met. Therefore, we decided that the 
Plan has to pre-approve a custom fabricated oral splint.  
 
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 Intracept device.
You asked the Plan to pre-approve an Intracept device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 an Intracept device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure. Therefore, the request is considered 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 an Intracept device have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee arthroscopy surgery.

You asked the Plan to pre-approve the knee arthroscopy surgery. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says the requested surgery is 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 the knee arthroscopy surgery. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the xrays submitted show advanced arthritis and there is no imaging study
confirming torn meniscus.

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 arthroscopy surgery have not been met. Therefore, we decided that the
Plan does not have to pre-approve knee arthroscopy surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve reconstruction of right shoulder joint (23472).

You asked the Plan to pre-approve reconstruction of right shoulder joint (23472). You say that the requested reconstruction of right shoulder joint (23472) is medically necessary. The Plan denied your request. The Plan says the requested reconstruction of right shoulder joint (23472) is 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 reconstruction of right shoulder joint (23472). Our reviewer says that the requested reconstruction of right shoulder joint (23472) is not medically necessary. Our physician reviewer found the enrollee is with osteoarthritis of right shoulder, with pain and decreased range of motion. Criteria for shoulder reconstructive surgery are not met. There are not enough conservative measures for the treatment of shoulder pain. A trial of physical therapy is needed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of reconstruction of right shoulder joint (23472) have not been met. Therefore, we decided that the Plan does not have to pre-approve reconstruction of right shoulder joint (23472).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a practical matter, can be provided at a lower 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 additional home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 14 additional home health PT visits. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 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 14 additional home health PT visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case; the 
documentation does not support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbation of chronic medical problems or hospitalizations. The 
requested home health services 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 14 additional home health PT visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 14 additional home health physical therapy (PT) visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF care. You say that you cannot walk and need this care. The Plan denied your request. The Plan says the enrollee can be treated at 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have no identifiable skilled nursing service needs. You do have skilled therapy service needs; however, you do not require skilled nursing or therapy services on a daily basis. You do 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 skilled nursing facility (SNF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) physical therapy visits.

You asked the Plan to pre-approve the physical therapy visits. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.

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 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 the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

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 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) 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 the enrollee's clinical condition meets full inpatient
acute rehab criteria. The lower level of care in skilled nursing cannot provide total IDT approach needed. The
Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary.
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 enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is no reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT), thorax, diagnostic; with contrast material(s) (71260) and computed tomography (CT), maxillofacial area; without contrast material (70486).

You asked the Plan to pre-approve the CT scans of the chest and face. You say that the CT scans are medically necessary. The Plan denied your request. The Plan says the requested CT scans are 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 scans of the chest and face. Our reviewer says that the CT scans are not medically necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has had a several week history of cough following mold exposure. The enrollee has a history of environmental allergies. No head and neck examination is documented. The lung examination is normal and no chest x-ray result is reported. The medical records provided do not support the medical necessity and reasonableness, as defined by Medicare rules. The elements of the coverage rules are not satisfied. The requested services are not recommended. 

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 scans of the chest and face have not been met.

Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT), thorax, diagnostic; with contrast material(s) (71260) and computed tomography (CT), maxillofacial area; without contrast material (70486).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled therapy facility (SNF) admission and services.

You asked the Plan to pre-approve SNF care. You say that the SNF care is medically necessary. The Plan denied your request. The Plan says there is not enough documentation to confirm medical necessity for transition to a SNF.

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 based on the limited documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a practical matter, can be provided at a lower 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled therapy facility (SNF) admission and services.