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

We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652) and sleeves for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the documentation did not indicate failure of conservative therapy.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic compression device (E0652) for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when the beneficiary has lymphedema of an extremity as defined above, the coverage criteria for an E0650 or E0651 are met and the beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial. 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 these services are not medically reasonable and necessary for the enrollee in this case. The enrollee has a diagnosis of postmastectomy lymphedema. She has had upper extremity cellulitis. Her lymphedema has been treated with compression garments, bandaging with PT, elevation and exercise. She has not trialed a basic lymphedema pump. Our physician reviewer found that the enrollee's condition does not meet Medicare 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 a Flexitouch pneumatic compression device (E0652) and sleeves for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing home services provided on January 1, 2019 through
February 1, 2019 by a non-Medicare certified provider.
You asked the Plan to pay for the nursing home services. You say that you made an outreach call to the facility
and received a letter that they are approved. The Plan denied your request. The Plan says this provider is not
certified with Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by [Provider Name].
This provider is not certified with Medicare. Therefore, we decided that the Plan does not have to pay for
nursing home services provided on January 1, 2019 through February 1, 2019 by a non-Medicare certified
provider.
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. You say that the enrollee has bilateral upper extremity weakness, and will benefit from acute inpatient rehab.The Plan denied your request. The Plan says the enrollee does not need an intensive rehab program, or supervision by a provider that specializes in rehab.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 is hemodynamically stable. Post-operatively, the enrollee's course included management of pain. The complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is at moderate to minimal assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (G0277).
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence that the radiation treatment caused osteoradionecrosis or soft tissue radionecrosis.
The Plan follows Medicare rules. Medicare rules say that [insert custom text from glossary].***} 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 hyperbaric oxygen therapy. Our reviewer says that this is not medically necessary at this time. Our physician reviewer found the submitted records show first minimal idiosyncratic reaction to therapy, including dry desquamation, vulvar sensitivity and urinary tract infection, and then a 2 cm hard prominent region on right labia that remains after radiation therapy. The records do not show a diagnosis of infection. No medications were prescribed. There was no documentation of an order for HBO. Based on the submitted records, the enrollee does not have a condition for which HBO is covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (G0277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 standard power mobility device.
You asked the Plan to pre-approve a power mobility device (K0800). You say that the enrollee needs a power mobility device. The Plan denied your request. The Plan says the home assessment is lacking as to the enrollee not having adequate upper extremity strength to self-propel a manual wheelchair.
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. The file does not show that the enrollee's condition cannot be improved by a manual wheelchair, or the enrollee can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 standard power mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ramp.
You asked the Plan to pre-approve the ramp. You say that this is medically necessary. The Plan denied your
request. The Plan says this is an item for personal comfort and convenience, and it is not covered.
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 a ramp.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the cervical spine.
You asked the Plan to pre-approve a CT scan of the cervical spine. You say that the requested CT scan of the
cervical spine is medically necessary. The Plan denied your request. The Plan says that the requested CT scan
of the cervical spine 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 a CT scan of the cervical spine. Our
reviewer says that the requested CT scan of the cervical spine is medically necessary. Our physician reviewer
found the enrollee is with C1-C2 deformity and fracture of cervical spine. Based on the documentation
provided for review, the CT scan is needed to show the upper cervical anatomy and deformity. It is the best test
to show the deformity. The requested CT scan of the cervical spine is medically reasonable and necessary for
the enrollee 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 a CT scan of the cervical spine have been met. Therefore, we decided that the
Plan has to pre-approve a CT scan of the cervical spine.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the power wheelchair repairs to be provided by the facility.
You asked the Plan to pre-approve the electronic harness and enhanced switch module. You say that the manufacturer has stated these items are not repairable under the warranty. The Plan denied your request. The Plan says that the repairs should be made by the manufacturer under warranty.
The Plan must follow Medicare rules. Medicare rules say that reasonable and necessary charges for maintenance and servicing are those made for parts and labor not otherwise covered under a manufacturer's warranty. We looked at the file and Medicare rules. The record shows the manufacturer says the parts are not repairable under warranty. Based on this information, we decided that Medicare rules for coverage of the electronic harness and enhanced switch module have been met. Therefore, we decided that the Plan has to pre-approve the power wheelchair repairs to be provided by the facility.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linzess capsules.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing based on medical necessity. 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 and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan also says that the enrollee's Medicare Part D prescription drug benefits may be administered by Express Scripts.
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 Linzess capsules.
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: 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 are 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 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 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) for
pneumonia, heart failure and a urinary tract infection (UTI). The enrollee has a tracheotomy stoma at baseline.
The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care,
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 (LTC) 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-approve long term acute care hospital (LTACH) 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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted
to acute care on 1/25/20 with sepsis secondary to bacteremia and aspiration pneumonia following his
oropharyngectomy 8 days prior on 1/15/2020, believed to be secondary to dysphagia. The enrollee is at risk for
aspiration, but recent records indicate the enrollee is afebrile and renal parameters are improving. There is no
fever. Medications include IV antibiotics. O2 is needed. Significant assist needed for lower body activities of
daily living. Endurance is poor; the enrollee needs minimal assist for mobility and transfers overall.
Records do not indicate that there are current significant, or complex medical/nursing issues that could not be
addressed at a lower level of care. Ongoing pain medication and other medication management, wound care,
and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly moderate to
minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of
therapy will allow for measurable gains to be attained within a predicted period.
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 IRF admission and services.You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you are progressing well at the skilled nursing facility, and have not had an acute change in condition to require close physician supervision or multiple specialty involvement.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 for acute care with acute hypoxic respiratory failure secondary to an exacerbation of chronic obstructive pulmonary disease and an upper respiratory tract infection. Your relevant past medical history also includes hypertension, hyperlipidemia, hypothyroidism, and stroke. Functionally, you are ambulating 42 feet with a cane. You require standby assistance when transferring from wheelchair to a bedside chair, and contact-guard assistance when transitioning from seated to standing. You require minimal assistance for toileting. Your medical conditions appear stable. There are no wound care needs. You are at the SNF level and do not require medical oversight of your condition at an acute hospital level of care. You are ambulating near household distances and do not require an intensive rehabilitation therapy program. You are limited by debility and the severity of your comorbid medical conditions. You would not be expected to be able to fully participate in or benefit from the required intensity of an acute 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-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan tablets for the enrollee.You asked the Plan to pre-approve Xifaxan. You say that this drug is medically necessary.The Plan denied your request. The Plan says this drug is not covered under 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 Xifaxan tablets for the enrollee.Benefits for Xifaxan 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 2, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet-rich plasma injections.
You asked the Plan to pre-approve the requested services. You say that you have bad knee pain and your doctor does not want to operate. The Plan denied your request. The Plan says the service is considered experimental, and unproven care for your condition.
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 platelet-rich plasma injections remain experimental for all orthopedic conditions. More research is needed to determine its efficacy. Therefore, the service is not considered 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve platelet-rich plasma injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an international hospital stay from June 15, 2019 to June 23, 2019.
You asked the Plan to pay for an international hospital stay. You say that you have submitted all the information you have. The Plan denied your request. The Plan says medical records have not been received so the services cannot be paid.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file did not contain medical records that show what services were performed or that said services were medically necessary. Without medical records, it cannot be established that coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of an international hospital stay have not been met. Therefore, we decided that the Plan does not have to pay for an international hospital stay from June 15, 2019 to June 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Doxepin for the enrollee.
You asked the Plan to pre-approve self-administered drugs under Medicare Part B. You say that this drug is medically necessary for the enrollee. The Plan denied your request. The Plan says this drug is not covered under 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 Doxepin for the enrollee.
Benefits for self-administered drugs under Medicare Part B may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.