Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve genetic testing (0037U) for the enrollee.

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says that a full clinical note was not submitted.

The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 testing. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found as a standard of care metastatic colon cancers should be tested for KRAS, NRAS, BRAF, HER2, and microsatellite Instability (MSI) or Mismatch Repair (MMR) Testing. Per the NCCN Guidelines these can be done individually or as part of next-generation sequencing [NGS panel]. NGS panels have the ability to pick up rare and actionable mutations and fusions. Universal genetic testing is recommended on all colon cancer tumors and NGS allows for initial screening with MSI testing. Other societies such as the American Society of Clinical Oncology also support the use of NGS. NGS offers the advantage of identifying markers known to have targeted therapy as well as potential clinical trials. As this enrollee may not be able to tolerate standard chemotherapy alternative treatment options should be sought out. The service is reasonable and medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have been met. Therefore, we decided that the Plan has to pre-approve genetic testing (0037U) for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 your medical conditions are stable and you have no complex nursing or rehabilitation needs. 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.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that it is not safe to be discharged home. The Plan denied your request. The Plan says that the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needs can be met at an alternate 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 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Physiatry and her hospitalist in the provided records both recommend acute inpatient rehabilitation facility placement after discharge. The enrollee does require physical therapy and occupational therapy services and both physical therapy and occupational therapy notes state that an intensive inpatient rehabilitation therapy program is required for her. There is a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 a group 3 power wheelchair with accessories (K0861, E1007, E2377, E2311, E1028, E1012, E1028, E2617, E2609, E0956, E1028, E2313, E2361, K0040, E0955, E2340, E0950).

You asked the Plan to pre-approve the group 3 power wheelchair with accessories. You say that the power wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says the power chair is for use in a Skilled Nursing Facility. Medical equipment for use inside a SNF is not eligible for separate coverage.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. 

Records show that the group 3 power wheelchair with accessories is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories (K0861, E1007, E2377, E2311, E1028, E1012, E1028, E2617, E2609, E0956, E1028, E2313, E2361, K0040, E0955, E2340, E0950).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis or at an inpatient level. 

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into a SNF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone scan (78306).

You asked the Plan to pre-approve the bone scan. You say that the bone scan is medically necessary. The Plan denied your request. The Plan says insufficient medical records were provided to support the request.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. The provider submitted insufficient clinical documentation to support the request. No progress notes were provided. Based on this information, we decided that Medicare rules for coverage of the bone scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone scan (78306).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty walker (E0149).
You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your request. The Plan says you do not qualify for this type of walker.
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for enrollees over 300 pounds. The medical notes indicate that you weight under 300 pounds. Based on this information, we decided that Medicare rules for coverage of the walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker (E0149).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cup holder for a wheelchair (K0108).

You asked the Plan to pre-approve the cup holder. You say that the item is medically necessary. The Plan denied your request. The Plan says the cup holder is not a covered item.

The Plan must follow Medicare rules. Medicare rules say that an option/accessory that is beneficial primarily in allowing the beneficiary to perform leisure or recreational activities is non-covered. 

We looked at the file and Medicare rules. The cup holder is considered a convenience item and is non-covered. Based on this information, we decided that Medicare rules for coverage of the cup holder have not been met. Therefore, we decided that the Plan does not have to pre-approve a cup holder for a wheelchair (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
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 service is medically necessary. The Plan denied
your request. The Plan says the service 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's medical conditions are stable and there are no complex nursing or
rehabilitation needs. 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.
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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
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 service is medically necessary. The Plan denied your request. The Plan says the service 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's medical conditions are stable and there are no complex nursing or rehabilitation needs. 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.
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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission to an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-preferred brand continuous glucose monitor (CGM).

You asked the Plan to pre-approve a non-preferred brand CGM. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says they will not cover other brands of CGMs unless the provider tells them it is medically necessary. The Plan says the provider has not told them why this enrollee requires the non-preferred brand CGM rather than a preferred brand.

The Plan must follow Medicare rules. The rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. 

We looked at the file, the Plan's contract and Medicare rules. The file shows the enrollee has not tried and failed the Plan's preferred brand CGM. There is no documentation showing that the enrollee has already been using the requested non-preferred brand CGM that is not yet out of warranty. There is no documentation showing why the enrollee requires the non-preferred brand CGM rather than a preferred brand CGM. Therefore, we decided that the Plan does not have to pre-approve a non-preferred brand continuous glucose monitor (CGM).
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 service is medically necessary. The Plan denied your request. The Plan says the service 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 medical conditions are stable and there are no complex nursing or rehabilitation needs. 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.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission to an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.

You asked the Plan to pre-approve the home health services. You say that you are blind and are afraid to leave your house. You say that you need to have blood work and vitals done. You say that you need someone to come to your house for this. You also say that your wife contacted your primary care physician's office was advised that you needed to be seen for an appointment. The Plan denied your request. The Plan says there is not a physician order for home health care services.

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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the file does not show that a physician has ordered the home health services. Additionally, the plan confirmed with your PCP office that you cancelled the appointment that you set up to talk about home health care. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303).

You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says you do not meet the requirements for this bed.

The Plan must follow Medicare rules. Medicare rules say that a bed coded with E03030 is covered for enrollees between 350 and 600 pounds. 

The records show that your current weight is between 310 and 320 pounds. Based on this information, we decided that Medicare rules for coverage of the bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303).