Persius/hicric huggingface dataset:
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 are compliant with therapy and would be able to participate in three hours per day. The Plan denied your request. The Plan says there is no need for the requested 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 enrollee is a female who presented to the hospital after fall resulting in a femoral neck fracture. This was treated surgically with no complications. She is weak and unsteady and is working with physical and occupational therapy. She is touchdown weight bearing with the right lower extremity and therapy notes indicate that ambulation could not be attempted on 03/23/2021 due to her inability to follow this limitation. She is moderate to maximum assist for transfers and moderate to maximum assist for activities of daily living. Confusion and disorientation are reported to be barriers to her learning with therapy. She is reported to be medically stable for discharge. 

Based on the medical records provided, the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but does not require an intensive inpatient rehabilitation therapy program. There is concern that the patient will not 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 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: 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 IRF level of care is medically necessary. The Plan denied your request. The Plan says the enrollee's therapy and nursing needs can be met at 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 enrollee presented to the hospital on 3/19/2021 after a fall with head trauma, but with no intracranial issues. She was treated in the hospital with antibiotics for a urinary tract infection and with amiodarone and Eliquis for atrial fibrillation which has stabilized. She is weak and deconditioned and is working with physical and occupational therapy. She is walking 200 feet with a rolling walker with contact guard assistance and is stand-by assist for transfers and maximum assist for some activities of daily living. Her therapy is reported to be limited by decreased endurance; she has had dizziness and headache with therapy. 

The records do not support that the complexity of the patient's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services, but based on the medical records, provided the patient does not require an intensive inpatient rehabilitation therapy program. There is concern that the patient will not 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a tertiary-level urologist for the enrollee.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated for urinary retention locally at a community center.

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 referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee can be treated for urinary retention locally by a community urologist. Urinary retention is a very common urological condition and is usually not treated at a tertiary center. 

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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral to a tertiary-level urologist for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve an interdental fixation device (21110).

You asked the Plan to pre-approve this item. You say that the device is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of this device.

The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this item. Our reviewer says that the device is medically reasonable and necessary. Our physician reviewer found that the use of intraoral appliances to treat this patient's temporomandibular joint disorder (TMD) is the result of derangement of the joints causing inflammation leading to dysfunction and pain; which is a medical condition. Therefore, criteria for coverage of this device have been met since this treatment is not related to the care, treatment, filling or replacement of the teeth or the structures supporting the teeth. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have been met. Therefore, we decided that the Plan has to pre-approve an interdental fixation device (21110).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vascular surgery services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the vascular surgery services. You say that you would like reconsideration because there are no vascular surgeons in-network. The Plan denied your request. The Plan says there are in-network options available to provide the requested service.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the vascular surgery services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with additional accessories and components.

You asked the Plan to pre-approve the Group 3 PWC as requested. You say that the enrollee is able to safely use this PWC. The Plan denied your request. The Plan says the only documentation that notes that the PWC can be safely used is from the supplier who has a direct financial interest in coverage of this equipment. Medical and therapy notes do not confirm that the PWC is safe for the enrollee.

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 3 PWC as requested. Our reviewer says that the documentation provided does not support that Medicare coverage criteria are met in this case. Our physician reviewer found the enrollee is a male with Parkinson's disease, gait instability, and dementia. There is documentation that this patient has a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. There is no documentation that the patient's mobility deficit cannot be helped by the use of a manual wheelchair with caregiver assistance. There is also no clear documentation to support that the enrollee can safely operate the PWC. A physical therapy note indicates that, in relation to a manual wheelchair, the enrollee is cognitively unable to coordinate for wheelchair mobility and safety. Although this applies to the use of a manual wheelchair, there is other documentation in the record from a visit on 2/26/2021 which calls into question the enrollee's ability to use the chair, noting that precautions were discussed including to refrain from driving and operating machinery. Without a clear endorsement from a medical professional stating that the use of the PWC is safe, the criteria are not considered to be met.

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 3 PWC as requested have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with additional accessories and components.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture.

You asked the Plan to pre-approve denture. You say that you have spaces where food accumulates and
damages your teeth. The Plan denied your request. The Plan says the denial of authorization for this service is
correct, because partial dentures are not covered when 8 or more posterior teeth are in occlusion.

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. The Plan covers denture when
the services are medically necessary and reasonable.

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 denture. Our reviewer says that you do
not meet the criteria for the requested partial denture. Our physician reviewer found a mandibular removable
partial denture is not medically necessary to provide you with adequate masticatory function.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of denture have not been met. Therefore, we decided that the Plan does not have to
pre-approve a mandibular partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral knee orthoses (L1851).

You asked the Plan to pre-approve bilateral knee orthoses. You say that the requested items are highly effective in reliving osteoarthritis pain and improving knee function. The Plan denied your request. The Plan says the provided medical records do not support a need for the requested items.

The Plan follows Medicare rules. Medicare rules say that knee orthoses are covered in case of recent injury to or a surgical procedure on the knee(s), or for objectively documented knee instability. 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 bilateral knee orthoses. Our reviewer says that the requested items are not medically necessary and reasonable. Our physician reviewer found that the documentation does not support that the enrollee has had a recent injury to or a surgical procedure on the knee(s). There is no date of injury or surgeries. The documentation notes that the enrollee is ambulatory but there is no objective evidence of knee instability on a physical examination. The coverage criteria per Medicare rules have not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral knee orthoses have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral knee orthoses (L1851).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tracheostomy supplies to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve the tracheostomy supplies. The Plan denied your request. The Plan says there are no gap issues and in-network providers are available.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve tracheostomy supplies to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that this service is considered experimental and investigational.

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. The Superion spacer
remains experimental. More research is needed to show safety and efficacy of the device. Open laminectomy is
the gold standard for spinal stenosis treatment. Our physician reviewer found that the enrollee's condition does
not meet 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 the Superion interspinous spacer for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve manual massage therapy to be provided by the
requested out-of-network provider.

You asked the Plan to pre-approve the manual massage therapy. The Plan denied your request. The Plan says
your Plan's Medical Group has in-network lymphedema therapists that can treat your condition.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist.

We looked at the file, the Plan's rule and the Medicare rules. The requested provider in this case is not a
network provider with the Plan. The Plan has network providers available who can provide the services at issue
in this appeal. Medicare does not cover the services of a massage therapist. We found no exception that would
require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to preapprove
manual massage therapy to be provided by the requested out-of-network provider.

Maximus Federal Services read your letter and knows that you may have a quality-of-care concern. Maximus
Federal Services cannot address quality of care issues. We are forwarding your quality-of-care concern to the
appropriate Quality Improvement Organization for further review.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for breast reconstruction surgery (19366) provided October 8, 2020.

You asked the Plan to pay for the breast reconstruction surgery. You say that the services were medically necessary. The Plan denied your request. The Plan says that the CPT code billed is not supported in the record.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 19366 is breast reconstruction, with other technique. 

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 breast reconstruction surgery. Our reviewers says that the records support the CPT code billed. Our physician reviewer found CPT code 19366 is a repair or a reconstruction procedure on the breast. The operative note indicates that lumpectomy was performed on the right and an equivalent amount was removed from the left breast. A Wise Pattern reconstruction was performed. The nipple-areolar complex was reset in the skin flap. The procedure as described represents a repair and reconstruction after right breast lumpectomy and left breast reduction for symmetry. 

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 breast reconstruction surgery have been met. Therefore, we decided that the Plan has to pay for breast reconstruction surgery (19366) provided October 8, 2020.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast.

You asked the Plan to pre-approve the requested services. You say that the enrollee has a family history of
cancer and has pain in the axillary breast tissue. The Plan denied your request. The Plan says the enrollee does
not have a personal history of breast cancer, or an inconclusive or positive mammogram.

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 requested services. Our physician
reviewer found that your last mammogram showed no evidence of malignancy and routine screening was
recommended. The records do not show that your diagnosis is inconclusive after a standard workup. The
records do not show that you have positive axillary nodes but no known primary. Therefore, the requested
testing 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 magnetic resonance imaging (MRI) of the breast.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve exercise equipment.

You asked the Plan to pre-approve the bike. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit and is not considered durable medical equipment.

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 exercise equipment.