Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty-four (24) additional PT visits.
You asked the Plan to pre-approve the PT visits. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.
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 PT 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 your condition. You have had extensive therapy for this condition and the documentation does not indicate that your functional level requires the ongoing 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 beyond what was approved by the plan. You have been approved for 12 out of the 36 requested visit and should be able to transition to an independent home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your 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 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twenty-four (24) additional PT visits.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvethe computed tomography (CT) scan of abdomen and pelvis both with and without contrast (74178).You asked the Plan to pre-approvethe CT scan of abdomen and pelvis. You say that the requested CT scan is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says that the CT scan is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan of abdomen and pelvis. Our reviewer says that the requested service is medically necessary and reasonable. Our physician reviewer found the patient is a 78-year-oldfemale with nausea aswell as abdominal, pelvic and perineal pain. Based on the provided documentation showing the patient having both abdominal and pelvic pain without a clear diagnosis yet, both the abdominal and pelvic CT with and without contrast is reasonable and 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 the CT scan of abdomen and pelvis have been met.Therefore, we decided that the Plan has to pre-approvethe computed tomography (CT) scan of abdomen and pelvis both with and without contrast (74178).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 toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea power wheelchair.You asked the Planto pre-approvethe wheelchair. You say that this is medically necessary.The Plandenied your request. The Plansaysthe notes do not show any problems with walking or doing activities of daily living.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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found it is not clear that your mobility deficit impairs participation in MRADLs. It is not clear why your deficit cannot be helped by the use of walker or manual wheelchair. The documentation does not indicate that you would be able to safely operate the requested wheelchair in your home, with adequate access between rooms and maneuvering space.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower seat elevation system (E2300), attendant control, proportional, including all related electronics andfixed mounting hardware (E2331), aftermarket back interface, joystick bracket receiver, power mount bracket, BodiLink head support pad 3, and BodiLink head support gt3 hardware, removable midline -flip down hardware.You asked the Plan to pre-approvethe items. You say that the member needs both tilt and recline functions as they have severe spasticity and history of pressure sores and ulcers.The Plan denied your request. The Plan says these items are not approved for coverage.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the items have not been met. The seat lift does not serve a primary medical purpose. An attendant control cannot be covered when a power wheelchair with a controller that is operated by the member is covered. These cannot be covered. The headrest, joystick and back cushion contain all parts for these items to function properly. These parts cannot be requested separately.Therefore, we decided that the Plan does not have to pre-approvepower seat elevation system (E2300), attendant control, proportional, including all related electronics and fixed mounting hardware (E2331), aftermarket back interface, joystick bracket receiver, power mount bracket, BodiLink head support pad 3, and BodiLink head support gt3 hardware, removable midline -flip down hardware.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that this is medically necessary to rehabilitate and effectively treat your broken leg.The Plan denied your request. The Plan says you do not need daily skilled services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF whenthe four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the submitted medical records, you do not have documented skilled nursing or therapy needs. You are ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial and, as a practical matter, can be provided at a lowerlevel 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe HYMOVIS injection rendered on September 29, 2020.You asked the Plan to waive the coinsurance forthese services. You say that you were not told there would be a coinsurance.The Plan denied your request. The Plan says the coinsurance was applied correctly.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 a 20% coinsurance for Medicare Part B prescription drugs. Review of the file shows that you received a HYMOVIS injection on September 29, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare Part B prescription drugs 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 forthe HYMOVIS injection rendered on September 29, 2020.
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 service is medically necessary. The Plan denied
your request. The Plan says services can be obtained 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 above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found there are no medical needs requiring inpatient admission. There are no complex
nursing or rehabilitation needs nor does the enrollee require an intensive rehabilitation program. 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. Specifically, the services can be obtained a lower
level of care. This means that IRF care is not reasonable or necessary. 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 IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you are unable to take part in 3 hours of therapy a day, and does not need an intensive team for 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 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 you were admitted to the acute hospital for vertigo after recent shoulder replacement surgery. You have been discharged home with home health care. You have ongoing weakness. Your medical conditions are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveradiofrequency ablation of the sacroiliac joint.You asked the Plan to pre-approvethe requested services. You say that the pain makes it difficult to get out of bed.The Plan denied your request. The Plan says the procedure has not been proven as effective as standard treatments of the sacroiliac(SI)joint.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 relevantMedicare 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,secondary to sacroiliitis and spinal stenosis. You havepositive provocative testing for SI joint pain. Yoursymptoms persist despite conservative treatments including medications, injections and facet radiofrequency ablation. Radiofrequency ablation used for sacroiliac joint pain is considered investigational, and not medically necessary whether performed using traditional, cooled, or pulsed radiofrequency. Completed studies say that this procedure does not improve outcomes compared to standard treatment. The requested radiofrequency ablation of the SI joints is not safe and effective for yourcondition. The requested service 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-approveradiofrequency ablation of the sacroiliac joint.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe drug regimen of  Pemetrexed, Carboplatin, and Pembrolizumab.You asked the Plan to pre-approvethe drug regimen. The Plan denied your request. The Plan says this combination of therapy is recommended for metastatic or stage IV disease.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 drug regimen. Our physician reviewer found that the enrollee has Stage IIIB/IIIC adenocarcinoma of the lung. There are no molecular studies available in the provided documentation. The drug regimen is approved for recurrent or metastaticadenocarcinoma of the lung with a non-mutated EGFR and ALK gene. This enrollee does not have recurrent or metastatic disease, and her EGFR and ALK is unknown. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 the drug regimen have not been met.Therefore, we decided that the Plan does not have to pre-approvethe drug regimen of  Pemetrexed, Carboplatin, and Pembrolizumab
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemonitored anesthesia care (MAC) to be performed during a colonoscopy.You asked the Plan to pre-approvethe MAC services. You say that the provider's policy is to use this level of sedation for all patients, and you feel that you should not be required to pay for this out of pocket.The Plan denied your request. The Plan says there is no medical necessity for this level of sedation documented. The Plan's network has other qualified providers who are able to provide this service with standard conscious sedation, as is appropriate in your case.The Plan must follow Medicare rules. Medicare rules say thatitems 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 MAC services. Our reviewer says that the requested level of anesthesia sedation is not considered medically reasonable and necessary in this case. Our physician reviewer found patients may undergo gastrointestinal (GI) endoscopic procedures without sedation, analgesia, or both.The majority of patients, however, receive some level of sedation and analgesia to relieve patient anxiety and discomfort and improve the outcome of the examination. The level of sedation and analgesia required to perform endoscopic procedures varies. Patient age, health status, concurrent medications, pre-procedural anxiety and expectation, as well as pain tolerance influence the level of sedation required to achieve the desired result, as do procedural variables such as the degree ofinvasiveness and the duration of the procedure. Conscious sedation and MAC are often used interchangeably for those undergoing GI procedures, but standard of care not provider or patient convenience warrants the latter in typically the most invasive procedural settings. The records in this case do not support that the risk factors warranting MAC are present, such as anticipated prolonged procedure time, advanced ASA classification, dysmorphia, history of or anticipated trouble with conscious sedatives. The request for MAC in this case fails to meet the accepted indication for MAC for a colonoscopy.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 MAC serviceshave not been met.Therefore, we decided that the Plan does not have to pre-approvemonitored anesthesia care (MAC) to be performed during a colonoscopy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blood vessel surgery.

You asked the Plan to pre-approve blood vessel surgery. You say that the veins are clogged and they do not allow blood to go to the legs. You say that you have difficulty walking without a walker. The Plan denied your request. The Plan says the information provided does not show the results of the tests done on the blood vessels that are to be operated on. The Plan says that, without this information, the medical necessity for the requested procedure has not been established.

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 blood vessel surgery. Our reviewer says that blood vessel surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not provide enough evidence that the enrollee is experiencing limb threat or that the enrollee's walking limitation is due to the condition being treated.  This is especially important as the planned aortobifemoral artery bypass surgery is a very invasive surgery with significant risk of morbidity and death.  Based on the physician assessment and plan it is unclear if the if the enrollee's chronic back pain and shortness of breath have been considered.  The enrollee requires a walker to walk short distances and has back pain.  The enrollee describes shortness of breath.  There is a history of lumbar discitis and lumbrosacral disk disease and bilateral LE neuropathy.  There is a history of scoliosis.  There is a history of placement of a spinal cord stimulator and thoracic laminectomy.  Noninvasive vascular studies including ABIs are not provided and the physical examination describes intact distal pulses.  For the procedure to be considered medically necessary, the surgeon's assessment and plan needs to address the enrollee's issues and rationale for the planed treatment in more detail.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of blood vessel surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve blood vessel surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on February 6, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and
paid. The Plan denied your request. The Plan says prior authorization was not obtained.
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 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 skilled nursing services provided on February 6,
2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe magnetic resonance imaging (MRI) of brain (70551).You asked the Plan to pre-approvethe MRI of brain. You say that this service is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says the MRI is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI of brain. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found the patient is an 86-year-old female with dizziness without other symptoms. Her vitals and neurology exam as listed in the chart notes were normal. Based on the limited support made in the documentation for this imaging, this service is not reasonable or necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI of brain have not been met.Therefore,we decided that the Plan does not have to pre-approvethe magnetic resonance imaging (MRI) of brain (70551)