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

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.

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 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 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required
(D2950)..

You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is
not covered under the enrollee's benefit plan.

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
core buildup, including any pins when required (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Exogen Bone Stimulator (CPT Code E0760).

You asked the Plan to pre-approve the bone stimulator. You say that the service is necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage, as there is no indication that the enrollee has had the required radiographs at 90-day intervals showing no significant healing, and the documented fracture does not meet the definition of a non-union fracture.

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 bone stimulator. Our physician reviewer found based on the medical records provided there is no documentation that meets the requirements listed in the LCD L33796 for Medicare coverage. The records do not document nonunion of the fracture in a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator separated by a minimum of 90 days. 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 bone stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve Exogen Bone Stimulator (CPT Code E0760
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI of a lower extremity joint (73721).

You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because your pain is affecting your quality of life. The Plan denied your request. The Plan says there is no history of conservative or non-surgical treatment.

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 MRI will be considered not medically necessary at this time based on the provided notes. Our physician reviewer found there was no mention of you having tried and failed a full course of physical therapy or formal home exercises/stretches as required to consider additional imaging.

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 the MRI of a lower extremity joint (73721).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied
your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer to 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 above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The enrollee continues to require skilled nursing and/or skilled therapy services on a daily basis. Although the enrollee is making slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. The enrollee can continue to received skilled rehab services at the current IRF. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve transfer to SNF care for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth #8.

You asked the Plan to pre-approve the dental service. You say that the enrollee needs the crown. The Plan
denied your request. The Plan says porcelain crown 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 a
porcelain crown (D2740) for tooth #8.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Group 3 Power Wheelchair with multiple power options, expandable controller, harness, electronics, power tilt and power recline.

You asked the Plan to pre-approve the wheelchair and upgraded electronics. You say that you would like reconsideration because the member requires a special wheelchair suspension and a power wheelchair with more than one power seat option. The Plan denied your request. The Plan says the notes do not show that this member needs power tilt and power recline, the seat lift is not medical in nature and there is no medical need to control more than 2 power options through the joystick.

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 wheelchair and upgraded electronics. Our reviewer says that the documentation does reveal the member mobility limitation is due to a neurological condition of multiple sclerosis. The member does not meet the coverage criteria for a power tilt and recline seating system. The member is not at high risk for development of a pressure ulcer and the member does not utilize intermittent catheterization for bladder management. The member does not use a ventilator. The power seating system is not needed to manage increased tone or spasticity. Our physician reviewer found the E2377 Expandable Controller and E2313 Expandable Controller Harness are not medically necessary. The documentation does not reveal that the member requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The member does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The member's strength and function are sufficient to control any power options through their own switches. 

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 wheelchair and upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve the Group 3 Power Wheelchair with multiple power options, expandable controller, harness, electronics, power tilt and power recline.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear.

You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says the benefit limit has been reached.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when up to $250 every year.

We looked at the file and the Plan's rules. The records show that the Plan paid $250 toward eyewear. You are responsible for any amount over the $250 benefit limit. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom abutment (D6057) and an abutment supported
crown (D6058).

You asked the Plan to pre-approve the dental services. You say that these services are urgent. You also say that
you need these services. The Plan denied your request. The Plan says custom abutment is not listed as a
covered service. The Plan also says that abutment supported crown 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 a
custom abutment (D6057) and an abutment supported crown (D6058).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the powered pressure reducing air mattress (E0277).

You asked the Plan to pre-approve the mattress. You say that you need it for your ulcers and the medical supply provider advised you that the air mattress was delivered back in April but you never received it. The Plan denied your request. The Plan says the records do not support the the enrollee meets the Medicare criteria for the requested item.

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 mattress. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to already have a hospital bed to help reduce and/or prevent pressure ulcer progression and there were no provided exam findings to determine the severity of current pressure ulcer to support this request. Therefore, this request for a powered pressure reducing air mattress will be considered not medically necessary at this time based on the provided documentation.

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 mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve the powered pressure reducing air mattress (E0277).
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 you would like reconsideration because the member requires interdisciplinary team approach and her needs cannot be met at a lesser level of care at this time. The Plan denied your request. The Plan says the member can safely receive care in an alternate setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is not a reasonable expectation that this member will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the suspension sleeve for lower extremity orthosis (L2397) and knee orthosis, adjustable knee joints (L1833).

You asked the Plan to pay for the suspension sleeve for lower extremity orthosis and knee orthosis, adjustable knee joints. You say that the services were medically necessary. The Plan denied your request. The Plan says there is no evidence the provider ever saw the member for an examination.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis is covered when knee instability is 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 suspension sleeve for lower extremity orthosis and knee orthosis, adjustable knee joints. Our reviewer says that the service is 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 suspension sleeve for lower extremity orthosis and knee orthosis, adjustable knee joints have not been met. Therefore, we decided that the Plan does not have to pay for the suspension sleeve for lower extremity orthosis (L2397) and knee orthosis, adjustable knee joints (L1833).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.

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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 

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 admission to a long term acute care hospital (LTACH).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 PWC with single power option and attachments.

You asked the Plan to pre-approve these services. You say that that this is medically necessary. The Plan denied your request. The Plan says that as you do not have need for power tilt or power recline, the request for K0856 Group 3 power wheelchair with single power option is not reasonable and 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. There is no documentation that you meet the criteria for a group 3 power wheelchair with single power option. Our physician reviewer found that your condition does not meet Medicare criteria for these services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 PWC with single power option and attachments.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this admission does not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for knee replacement surgery. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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).