Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says yourcare is not complex, and you donot need a team of providers.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 weredischarged from rehab, and presented to the hospital the next day with lower extremity weakness. A urinary tract infection was diagnosed, and antibiotics were started. The documentation raises doubt that youwill be able to fully participate in and benefit from the intensive rehabilitation therapy program at least 3 hours a day. The complexity of yournursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You donotrequire physical or occupational therapy in an intensive rehabilitation therapy 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-approveacute 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 hospital care. 
 
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says the enrollee 
could be treated at a lower level, such as observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient services. Our physician 
reviewer found that the enrollee presented to the emergency department reporting chest pain and dizziness.  
Emergency care included an electrocardiogram, radiology studies, laboratory tests, aspirin and morphine. The 
enrollee was noted to be bradycardia, but chest discomfort improved. The enrollee was maintained on 
telemetry, and was noted to have ongoing bradycardia. The enrollee was followed by cardiology. Additionally, 
the enrollee was evaluated by endocrine specialists for marked hypothyroidism. There were no advance 
interventions or complex medical conditions. The enrollee had stable vital signs and no complaints. Therefore, 
inpatient services are not supported by the documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services required exceed the clinical 
capabilities of lower levels of care. The Plan denied your request. The Plan says the documentation does not 
support a need for long term acute care. 
 
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 to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician 
reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical 
services that are materially different than those of short term acute care hospitals. In this case, ongoing care 
needs include oral seizure medications,  surveillance laboratory studies, tube feeding, and therapy services. 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MAKOplasty for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this procedure is not proven by medical evidence. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has been recommended for a MAKOplasty unicompartmental knee arthroplasty. No patient-
specific indication is provided to support the medical necessity of the MAKOplasty procedure over standard 
unicompartmental knee arthroplasty. The submitted literature in support of this request was reviewed. There is 
a lack of large volume, long-term peer-reviewed outcome studies presented to support the use of these 
procedures for this patient. Therefore, this request for the MAKOplasty procedure would not be considered 
medically reasonable and necessary for this enrollee's medical condition. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve MAKOplasty for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the in-home provider services to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve the OON in-home provider services. You say that these services are 
medically necessary and should be approved. The Plan denied your request. The Plan says the requested 
medical care is available from network providers. As such, OON care is not medically required. 
 
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 in-home provider 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-approvea CPAP device and supplies.You asked the Plan to pre-approvethe CPAP and supplies. You say that you would like reconsideration because you have sleep apnea.The Plan denied your request. The Plan says you have not had a sleep study in the past year.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 CPAP and supplies. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the LCD criteriayou do not fulfill criteria without an in-person examination or sleep study in the past year.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 CPAP and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approvea CPAP device and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory assist device and a humidifier for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the compliance report does not meet standards. 
 
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 device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the compliance report from 8/2/20-8/31/20 documents usage days of 4 hours or more during 33% of the 
days. Her average nightly use is 3 hours, 18 minutes. The documentation does not support adherence to 
therapy, defined as use of PAP for four hours of more per night on 70% of nights during a consecutive thirty 
day period anytime during the first three months of initial usage. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a respiratory assist device and a humidifier for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Januvia tablets. 
 
You asked the Plan to pre-approve self-administered drugs. You say that this drug has controlled the enrollee's 
condition. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Januvia tablets.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because these 
orthotics are medically necessary and a Medicare covered benefit. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not wear a leg brace. Orthotics for treatment of diabetic foot ulcers utilize different 
codes. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of 
orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466) and humidifier (E0562). 
 
You asked the Plan to pre-approve a ventilator and humidifier. You say that the enrollee needs this device. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator and humidifier. Our 
reviewer says that the requested ventilator is not medically necessary in this case. Our physician reviewer 
found the enrollee has COPD and morbid obesity, with frequent hospitalizations for COPD exacerbations. The 
patient has previously been on a Trilogy ventilator at home but it was removed because of lack of usage.  There 
is no arterial blood gas data to document CO2 retention while in a stable state. There is no evidence of failure 
of BiPAP. The patient improved on BiPAP in the hospital. 
 
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 ventilator and humidifier have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a ventilator (E0466) and humidifier (E0562).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar epidural steroid injections. 
 
You asked the Plan to pre-approve the injections. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says there has not been a failure of all 
of the appropriate non-surgical conservative care. 
 
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 injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that the enrollee has tried and failed aqua therapy as suggested by the 
prescriber.  Additionally, he record documents that the last block procedure did not provide any relief. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar epidural steroid injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller and related items (E2311, 
E2377, E2313). 
 
You asked the Plan to pre-approve the expandable controller and related accessories. You say that the 
expandable controller is medically necessary. The Plan denied your request. The Plan says coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers for Power Wheelchair are 
covered when 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 expandable controller and related 
accessories. Our reviewer says that the requested expandable controller is not medically necessary. Our 
physician reviewer found the provided notes suggest that the enrollee is able to use the available power controls 
which would negate the need for an expandable customized controller in this case. 
 
 
 
 
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 expandable controller and related accessories. have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller and related items (E2311, 
E2377, E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting 
review of denial of services. The Plan denied your request. The Plan says you exhausted your benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of six (6) one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 7th trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation trips.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health services. 
 
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says the 
enrollee has no exacerbation of his medical condition. 
 
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. 
 
The file shows that the original request was for 9 home health skilled nursing services, 18, physical therapy 
services, and 18 occupational therapy visits. The plan agreed to pre-approve 5 nursing visits, 6 physical 
therapy, and 6 occupational therapy visits. 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 additional services. Our physician reviewer found that the enrollee has had prior skilled nursing for 
disease and medication management and education. The enrollee's conditions are chronic. There is no evidence 
of complex wound care or other skilled nursing needs. The records do not show that skilled therapy services are 
required to effectively provide treatment in order to improve the enrollee's level of function, or to 
establish/perform a maintenance program to maintain his level of function or prevent deterioration. The 
enrollee is at a high functional level for activities of daily living, ambulation, and transfers, and no longer 
requires the ongoing skills of physical and occupational therapy. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (CMT); spinal, 3-4 
regions (CPT Code 98941). 
 
You asked the Plan to pre-approve the services. You say that the chiropractic services are necessary and are 
effective. The Plan denied your request. The Plan says maintenance therapy is not a covered benefit. The Plan 
states according to documentation further clinical improvement cannot be reasonably be expected form 
continuous ongoing care. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Maintenance therapy is not a covered benefit. Requests show that 
recent treatment did not help with your daily tasks. Requests also show no change in pain levels with recent 
care. Other treatment options may be needed instead. This type of care is only approved for some problems of 
the spine. Treatment must lead to recovery or improved function. Since the records show that your complaints 
did not improve enough with recent treatment, this request is not approved. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic manipulative treatment (CMT); spinal, 3-4 regions (CPT Code 
98941).
Appeal type: Surgery
Decision: Favorable

     We decided that the Plan has to pre-approveinpatient surgery (transcatheter mitral valve implantation/replacement (TUMVI)with prosthetic valve (0483T)).

You asked the Plan to pre-approvethe services. You say that the service is necessary.The Plan denied your request. The Plan says that the services are not 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 the services. Our physician reviewer found based on the records the patient has severe symptomatic bioprosthetic mitral valve stenosis and is not a candidate for redo surgery.  In this circumstance, the only feasible treatment option is placement of a transcatheter mitral valve-in-valve. The coverage criteria above do not apply since those criteria are for aortic valve replacement. There has been recent literature in support of transcatheter mitral valve in valve replacement when all other options are exhausted, as in this case.

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 services have been met.Therefore, we decided that the Plan has to pre-approve inpatient surgery (transcatheter mitral valve implantation/replacement (TUMVI)with prosthetic valve (0483T)). 

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.