Persius/hicric huggingface dataset:
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 the enrollee does not 
require an intensive, complex, multidisciplinary approach to daily therapy. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for syncope and a COVID-19 infection. His medical 
conditions are stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe urgent medical services provided from August 30, 2019, to August 31, 2019.You asked the Plan to pay forthe services provided. You say that the services were charged to a credit card.The Plan denied your request. The Plan says no receipt or invoice was provided to show the charges were from an emergency room visit.The Plan must follow Medicare rules. Medicare rules say that the beneficiary must furnish sufficient informationto determine whether payment is due, and the amount of payment. We find that payment for the medical servicesis not supported in the provided documentation. The records do not include a claim, or itemized invoice showing what specific services were provided, and how much was charged for each service. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe urgent medical services provided from August 30, 2019, to August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe CardioMEMS HF system for the enrollee.You asked the Planto pre-approvethe system. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no enrollment in a Medicare-approved study which is looking at the benefits of this device.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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance, therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 system have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe CardioMEMS HF system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cranial prosthesis (wig). 
 
You asked the Plan to pre-approve wig. You say that you feel uncomfortable with not having hair and feel the 
Plan should assist with coverage for a wig. The Plan denied your request. The Plan says the denial of 
authorization for this item is correct, because wigs are not covered by Medicare. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a cranial 
prosthesis (wig).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNM thyroid radiation therapy.You asked the Plan to pre-approveNM thyroid radiation therapy. You say that the records provided support the need for the requested treatment.The Plan denied your request. The Plan says NM thyroid radiation therapy is not supported or considered 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 NM thyroid radiation therapy. Our reviewer says that NM thyroid radiation therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found radiation therapy would not be indicated unless the enrollee had documented thyroid cancer, and even then, would only be indicated in certain situations. The scan and uptake would also not be indicated unless the TSH is low. This does not appear to be the case, as the enrollee shows to have had a normalTSH in 2019. The TFTS from the February 6, 2020, were not provided.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of NM thyroid radiation therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveNM thyroid radiation therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea semi-electric hospital bed (E0260).You asked the Plan to pre-approvea semi-electric hospital bed. You say that the item is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.We askedour 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 semi-electric hospital bed. Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation does not clearly reveal that your condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent change in body position or that you have a condition that needs special attachments that cannot be fixed on an ordinary bed. The face to face evaluation states that it was completed on February 15, 2021 (date of your surgery) but this date has not occurred yet. The request for a semi-electric hospital bed 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 a semi-electric hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approvea semi-electric hospital bed (E0260).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, spinal canal and contents, lumbar; without contrast material (CPT Code 72148).

You asked the Plan to pre-approve the MRI. You say that you intend to submit documentation to show medical necessity. The Plan denied your request. The Plan says no medical records were sent for review and numerous attempts were made to obtain records.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. There is insufficient medical documentation to verify if the MRI is necessary. Therefore, we decided that the Plan does not have to pre-approve MRI, spinal canal and contents, lumbar; without contrast material (CPT Code 72148).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveeight physical therapy visits.You asked the Plan to pre-approvethe eight physical therapy visits. You say that further physical therapy is needed to restore the prior level of function and modalities.The Plan denied your request. The Plan says the requested physical therapy is not medically necessary, as the enrollee can be managed with a home program.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 eightphysical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this question and the documentation does not indicate that his functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has had instruction on mobility, safety, home exercises. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not requiredto establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 8 physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approveeight physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on August 6. 2020.

You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided on August 6. 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for shoulder replacement surgery to be provided by the out-of-network provider.You asked the Plan to pre-approve inpatient admission for shoulder replacement surgery to beprovided by the out-of-network provider. The Plan denied your request. The Plan says care from out-of-network providers will not be covered.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for shoulder replacement surgery to be provided by the out-of-network provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested dialysis treatments. 
 
You asked the Plan to pre-approve dialysis treatments. The Plan denied your request. The Plan says services 
with an out-of- network provider may be approved if the enrollee requires urgent or emergent care, if the Plan 
does not have providers that can provided the needed care, or if the enrollee needs kidney dialysis when out of 
the Plan's service area. 
 
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 services at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested 
dialysis treatments.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that care in an LTACH is medically necessary.The Plan denied your request. The Plan says the enrollee can continue to get the acute care needed in the current health care setting.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 todetermine 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 the enrollee is currently undergoing treatment at an acute care hospital (ACH), having been admitted with COVID-19 in the setting of chronic debilitation.  The enrollee was eventually intubated/ventilated and received a tracheotomy.  The enrollee remains on a ventilator and is noted to not be appropriate for weaning at this time.  There is no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such time no acute services are required.  The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.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-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and sleeves (E0667).You asked the Plan to pre-approvea pneumatic compression device and sleeves. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that a 4week trial on an E0650 or E0651 with failed response is required.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and sleeves (E0667)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer device. 
 
You asked the Plan to pre-approve the requested services. You say that the treatment is supported by its clinical 
benefits to patients. The Plan denied your request. The Plan says 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 the requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. She takes Gabapentin, Advil, ice and heat for pain. 
She had a trial of physical therapy, which did not help. She also tried Transforminal Epidural steroids, and the 
pain did not improve. Imaging shows central and foraminal spinal stenosis. The requested interspinous spacer 
device is considered an experimental/investigational procedure.  Therefore, the request is considered 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 an interspinous spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of a group 2 power wheelchair with a group 3 power wheelchair and accessories.

You asked the Plan to pre-approve replacement of a group 2 power wheelchair with a group 3 power wheelchair and accessories. You say that the requested items are necessary.The Plan denied your request. The Plan says the current power wheelchair is less than five years old. Therefore, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that Medicare pays for the least expensive option of repair vs.replacement of durable medical equipment (DME). Replacement due to wear is not covered during the reasonable useful lifetime of the equipment.


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 replacement of a group 2 power wheelchair with a group 3 power wheelchair and accessories. Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation reveals the enrollee has sufficient right upper extremity strength and function to operate any power options through their own individual 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 replacement of a group 2 power wheelchair with a group 3 power wheelchair and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvere placement of a group 2 power wheelchair with a group 3 power wheelchair and acces
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair (PWC) with multiple power options and other related accessories.You asked the Plan to pre-approvethe Group 3 PWC. You say that the treating physician feels that a Group 3 PWC is the best option for the enrollee's condition.The Plan denied your request. The Plan says Medicare criteria are not met for the Group 3 PWC as the enrollee's mobility limitation is not due to a qualifying condition.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to a neurological condition, myopathy, or congenital skeletal deformity.The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have to pre-approvea Group 3 power wheelchair (PWC) with multiple power options and other related accessories