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

We decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve CGM. You say that you have diabetes, are testing four times per day, and inject insulin twice per day. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because you do not meet the Medicare criteria for a continuous glucose monitor.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the physician's services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Our physician reviewer also found that there is not a 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Azathioprine.

You asked the Plan to pre-approve Azathioprine. You say that Azathioprine and Prednisone are the standard of care for treatment for the enrollee's diagnosis. The Plan denied your request. The Plan says the enrollee's Medicare Part B plan does not cover Azathioprine for their diagnosis of Rheumatoid Arthritis.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 Azathioprine. Our reviewer says that Azathioprine is not medically reasonable and necessary for the enrollee. Our physician reviewer found the review has determined that the documentation does not support that the Azathioprine is medically reasonable and necessary for the enrollee. Our reviewer also found that the documentation does not support that the Azathioprine is safe and effective for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Azathioprine have not been met. Therefore, we decided that the Plan does not have to pre-approve Azathioprine.
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 you do 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 file shows that you are 78 years of age. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy.

You asked the Plan to pre-approve the requested services. You say that other means of radiation therapy would result in additional adverse outcomes and damage to other organs. The Plan denied your request. The Plan says the medical records provide no plausible benefit for the use of proton beam therapy over intensity modulated radiation therapy (IMRT).

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 requested services. Our physician reviewer found that any potential benefit or detriment of proton therapy over standard IMRT is an investigational question. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. 

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional OT services performed in the home health or hospice setting (G0152).

You asked the Plan to pre-approve the additional OT services. You say that you still need the OT services. The Plan denied your request. The Plan says additional OT services are not medically necessary.

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 the additional OT services. Our reviewer says that the additional OT services are not medically reasonable and necessary. Our physician reviewer found the documentation does not support that you require skilled rehab services to provide treatment that is medically necessary. You do not require skilled rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. Our reviewer found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Our physician reviewer also found that the previously authorized 5 occupational therapy sessions are adequate to establish an effective home exercise 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 the additional OT services have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional OT services performed in the home health or hospice setting (G0152).
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 would like additional home health services to be approved. The Plan denied your request. The Plan says your current needs do not appear to be skilled in nature.

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 the home health services. Our reviewer says that the home health services are not medically reasonable and necessary. Our physician reviewer found the documentation does not support that you require skilled nursing services or skilled rehab services to provide treatment that is medically necessary. Our reviewer found that you do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. Our physician reviewer also found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.

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 health services have not been met. 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 the group 1 power operated vehicle (K0800).

You asked the Plan to pre-approve the group 1 power operated vehicle. You say that this this item is medically necessary for your condition. The Plan denied your request. The Plan says the power operated vehicle is not medically necessary for your condition as there is no evidence that your personal mobility deficit impairs participation in MRADLs in the home.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 group 1 power operated vehicle. Our reviewer says that the requested power operated vehicle is not medically necessary and reasonable. Our physician reviewer found there is no evidence that you have a mobility deficit that impairs MRADL participation in the home. There is no evidence that you are unable to effectively resolve any mobility limitation with a walker or manual wheelchair or safely operate the requested power operated vehicle in her home. 

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 group 1 power operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 1 power operated vehicle (K0800).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee requires and would benefit from intensive inpatient rehab hospitalization. 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Our physician reviewer also found that there is not a 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment.

You asked the Plan to waive the coinsurance for the services. You say that you thought that insurance was going to cover this entirely. The Plan denied your request. The Plan says the claim was processed appropriately according to your benefits and the services rendered.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment.

You have been asked to pay 20% coinsurance for the services. The services fall within the durable medical equipment category benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for durable medical equipment.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
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 feel that you need this level of care to manage your condition. The Plan denied your request. The Plan says your medical conditions are stable, and there is no clear need for intensive rehabilitation services.

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 patient was admitted for hip pain and an infected pressure ulcer. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services.

You asked the Plan to pay for air ambulance services. You say that you would accept ground ambulance level payment. The Plan denied your request. The Plan says ambulance services were not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

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 air ambulance services. Our reviewer says that the ambulance service was not medically necessary. Our physician reviewer found the enrollee was hemodynamically stable. Air transport was requested as there were no ground transports available. The enrollee was transported without incident or any need for additional intervention (no oxygen, no medication) during transport.

1. There was no indication from the provided notes that other means of transportation were contraindicated, namely stretcher van or wheelchair van. 
2. The patient did not require special equipment or expertise during transport. Treatment was already initiated with the PCP and only transportation was needed. Blood pressure was beginning to reduce after initial treatment. 
3. There is insufficient evidence to support the need for ambulance services
4. The member did not meet the criteria for ground ambulance 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.

You asked the Plan to pre-approve the requested services. You say that your pain is intense and getting worse. The Plan denied your request. The Plan says there is no documentation of a second medial branch block.

The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered under certain medical indications.

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 requested services. Our physician reviewer found that you have chronic low back pain. You have had sacroiliac joint injections 5 times. You had one set of left diagnostic medial branch blocks at L3, L4, and L5, which produced 80% pain relief for 2 days. You did not have a second confirmatory set of blocks. The request is for radiofrequency ablation. Coverage criteria requires a second confirmatory set of diagnostic medial branch blocks. Therefore, at this time, the request is not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal canal catheter implant (62350), spinal infusion pump implant (62362), and infusion pump (E0783).

You asked the Plan to pre-approve a spinal canal catheter implant, spinal infusion pump implant, and infusion pump. You say that the items are medically necessary. The Plan denied your request. The Plan says they did not receive documentation assessing the patient's tolerance or acceptance of therapy and while a decrease in pain score was documented, there was no documentation regarding impact on activities of daily living (ADLs).

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 spinal canal catheter implant, spinal infusion pump implant, and infusion pump. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found documentation has not been provided assessing the patient's tolerance or acceptance of therapy. Further, while a decrease in pain score was documented, there is no documentation regarding impact on ADLs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal canal catheter implant, spinal infusion pump implant, and infusion pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal canal catheter implant (62350), spinal infusion pump implant (62362), and infusion pump (E0783).