Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial foot prosthesis (L5020).

You asked the Plan to pre-approve partial foot prosthesis. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says the requested equipment exceeds the
member's needs.

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 partial foot prosthesis. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the requested prosthesis exceeds the member's medical needs. The documentation
does not indicate why a partial foot, molded socket, tibial tubercle height, with toe filler is needed over a partial
foot, shoe insert, with longitudinal arch toe filer.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of partial foot prosthesis have not been met. Therefore, we decided that the Plan
does not have to pre-approve partial foot prosthesis (L5020).
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 April 7, 2021 and forward.

You asked the Plan to pre-approve the continuation of inpatient mental health care from April 7, 2021 and forward. You say that the continuation of inpatient mental health care from April 7, 2021 and forward is medically necessary. The Plan denied your request. The Plan says the continuation of inpatient mental health care from April 7, 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 April 7, 2021 and forward. Our reviewer says that the continuation of inpatient mental health care from April 7, 2021 and forward is not medically necessary. Our physician reviewer found this enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based upon review of the
records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of April 7, 2021 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to 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 April 7, 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 April 7, 2021 and forward.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance spectroscopy (MRS) (76390).

You asked the Plan to pre-approve resonance spectroscopy. You say that this is necessary to diagnose a mass on your brain. The Plan denied your request. The Plan says this is not a covered service.

The Plan follows Medicare rules. Medicare rules say that MRS is not covered for any indication.

We looked at the file and Medicare rules. The requested service is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance spectroscopy (MRS) (76390).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve these services. You say that the enrollee needs the portable oxygen for
travel. The Plan denied your request. The Plan says you have a stationary oxygen concentrator and portable
oxygen tanks.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary. The rules state that for equipment to be covered, it must be appropriate and needed
for use inside the home.

The file shows that you have a stationery oxygen concentrator and a portable oxygen tank. These items serve
the same purpose as the requested portable oxygen concentrator. Furthermore, the portable oxygen is being
requested for travel, and Medicare does not cover DME for use outside of the home. Therefore, we decided that
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. 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. The enrollee's care needs at this point 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total shoulder arthroplasty.

You asked the Plan to pre-approve total shoulder arthroplasty. You say that you would like reconsideration
because this procedure is medically necessary. The Plan denied your request. The Plan says there is no imaging
to show this is 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 total shoulder arthroplasty. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent,
reasonable and comprehensive less invasive conservative care measures. There is no compelling rationale
presented or extenuating circumstances noted to support the medical necessity of this request as an exception.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of total shoulder arthroplasty have not been met. Therefore, we decided that the
Plan does not have to pre-approve total shoulder arthroplasty.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the member has stabilized medically
and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled
therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level
of care. Although further rehab services would be appropriate to improve function, as a practical matter, the
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility.
The member does not have any parental medication; complex wound care or nutrition given via a feeding tube.
She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is
at or near her baseline and she can receive services at a lower level of care. 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of inpatient skilled nursing facility 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 inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that you have stabilized medically and have been receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF). You have tolerated inpatient rehabilitation services and continue to improve with daily skilled nursing and/or skilled therapy services. You could benefit from continued services at the current level of care. There is no indication that a transfer to a skilled nursing facility is required. You can continue to receive skilled rehabilitation services at the current IRF facility or be stepped down to a lower level of care when appropriate. There are no services offered at a skilled nursing facility that are not offered at an inpatient rehabilitation facility. Admission to a SNF for inpatient skilled rehabilitation 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 inpatient skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. 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. The enrollee's care needs at this point, 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung
cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that you disagree with the denial. The
Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung
cancer screening for enrollees who meet all the above-described criteria.
We reviewed the file and the Medicare rules. The records show that the enrollee does not have a smoking
history of at least 30 pack years. Therefore, we decided that the Plan does not have to pre-approve a low dose
computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatment to be provided by an out of network (OON) licensed acupuncturist.
You asked the Plan to pre-approve the OON acupuncture treatment. You say that these services are medically necessary to treat her back pain. The Plan denied your request. The Plan says this provider is not a Medicare-covered acupuncture provider and is out of network with the Plan.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan also offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the Medicare rules for coverage of the acupuncture services have not been met. Specifically, this provider is not a physician, physician assistant, or nurse practitioner/clinical nurse specialist. There is no evidence that this provider is under supervision of one of these provider types. The Plan's internal rules are also not met as this provider is OON. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatment to be provided by an out of network (OON) licensed acupuncturist.
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 the requested CGM is medically necessary. The Plan
denied your request. The Plan says the enrollee does not meet criteria for the requested CGM.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that the
enrollee does not meet criteria for the requested CGM. Our physician reviewer found based on the
documentation provided, the enrollee is noted to be a diabetic, who takes a set dose of insulin at bedtime and a
sliding scale of insulin with meals. How often the enrollee tests his blood glucose level is not noted (i.e., no BG
log or office download/discussion). Therefore, there is no evidence that the enrollee actually tests his blood
glucose multiple times per day and uses this information to self-adjust his insulin doses multiple times per day.
As such, the requested CGM is not currently shown to be medically necessary or reasonable. Submission of a
BG/insulin administration log to the Plan would likely make this CGM coverable.
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 CGM have not been met. Therefore, we decided that the Plan does not have to
pre-approve a continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that admission to the SNF is necessary to meet his needs. The Plan denied your request. The Plan says the enrollee's needs are not skilled.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was recently admitted to an acute care hospital on 3/16/21 due to altered mental status due to a large subdural hematoma. He underwent a left craniotomy with evacuation of an acute subdural hematoma. He stabilized medically and was discharged to an inpatient rehab facility on 3/31/21. The member has stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The member has tolerated inpatient rehab services and continues to improve with daily skilled nursing and/or skilled therapy services. He could benefit from continued services at the current level of care. The member has made slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the member can safely receive services in a lower 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 not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex nursing or rehabilitation needs. Medically necessary care can be rendered at a lower 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 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: 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 services.
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. The enrollee's care needs at this point 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a humidifier.
You asked the Plan to pre-approve a humidifier. You say that you need this and cannot afford it. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a humidifier.