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

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that in 2010 you were in a car accident in which your foot was severed and had to be reattached. You say that you have weight bearing limitations, no flexibility in the tendon in your foot and no ability to push up and down. You stated that standing in the shower is impossible and you cannot stand for more than 30 minutes at a time. You say that you previously had a showerchair but it became old and not very durable.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that the enrollee needs the requested orthotics for her foot pain. You say that the orthotics are needed for the enrollee's care.The Plan denied your request. The Plan says this item is nota 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition. Therefore, we decided that the Plandoes not have to pre-approvefoot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that you are not able to go home.The Plan denied your request. The Plan says the services are not medically necessary.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 services are not medically necessary. Our physician reviewer found you were admitted to the hospital one June 2, 2020 with increasing symptoms of narrowing of the neck spine (cervical spinal stenosis). You underwent spine surgery on June 4, 2020. You have had no post-operative complications and are medically stable. You have no complex medical, nursing, or rehabilitation needs that require supervision by a physical medicine and rehabilitation physician or acute rehab nursing care. You may benefit from further therapy but do not require an intensive therapy program 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.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 long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that it is better to go Select Specialty Hospital instead of just a rehab center.The Plan denied your request. The Plan says the enrollee does not have the severity of illness that requires this level of admission.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 ACH for an asthma exacerbation in the setting of morbid obesity. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nitrile exam gloves. You asked the Plan to pre-approve Nitrile gloves. You say that the enrollee has a tracheostomy and needs a lot of care which includes frequent suctioning, daily inner cannula changing and gauze dressings changings. All of these require Nitrile gloves. The Plan denied your request. The Plan says this item 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 Nitrile exam gloves.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LINX Reflux Management System and laparoscopic placement (43284).
You asked the Plan to pre-approve a LINX Reflux Management System and laparoscopic placement. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is not covered.
The Plan must follow Medicare rules. Medicare rules say that the services represented by CPT 43284 are not covered. We looked at the file and Medicare rules. The requested procedure is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of a LINX Reflux Management System and laparoscopic placement have not been met. Therefore, we decided that the Plan does not have to pre-approve a LINX Reflux Management System and laparoscopic placement (43284).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IMRT treatment out of network. You asked the Plan to pre-approve out of network providers. You say that while this treatment may be available in network, the treatment you offer is unique and should be considered for the enrollee. The Plan denied your request. The Plan says there are providers in network who can provide these services. 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 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 preapprove these services. Therefore, we decided that the Plan does not have to pre-approve IMRT treatment out of network.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 the enrollee required minimal assistance for bed rolling. The enrollee required
moderate assistance with sit up and lie down. The enrollee required contact guard assistance with sitting. The
documentation does not support that the enrollee requires the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of
rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level
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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee's physical medicine and rehabilitation doctor and clinical rehabilitation specialist both agree that she is an appropriate candidate for inpatient rehabilitation. You say that the therapy needed cannot be provided at a lesser intense level of care. The Plan denied your request. The Plan says the records do not indicate that the criteria for coverage have been met. The Plan says that the needed services can be received in another setting.
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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.You asked the Plan to pre-approve a total electric hospital bed. You say that the requested bed is medically necessary.The Plan denied your request. The Plan says a total electric hospital bed is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Plan to pre-approve the admission. You say that this will be beneficial to be able to return home and take care of yourself.The Plan denied your request. The Plan says needs can be met at a lower level of care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approve SNF services. You say that the enrollee needs therapy to regain his strength.The Plan denied your request. The Plan says the enrollee has no medical or therapy needs that require skilled services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs, and was treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a contact guard to minimal assist level for functional mobility. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided January 6 to January 9, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that the inpatient care was not authorized and was not medically necessary.
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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the admitting physical could have reasonably expected that the enrollee's care would span more than two midnights. Inpatient level care was 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided January 6 to January 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nortriptyline.You asked the Plan to pre-approve Nortriptyline. You say that you need the medication to treat your migraines.The Plan denied your request. The Plan says this drug is not covered for your condition by your Part B plan.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 Nortriptyline.Benefits for Nortriptyline 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty 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 is not 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 the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not show that the enrollee has pain in the region of the T12 fracture. The imaging studies show lower lumbar degenerative changes and the records indicate low back pain. Pain from the T12 fracture region has not been described. 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 kyphoplasty for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nursing and aide visits.You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the enrollee does not need additional training for his problems.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.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 home health services. Our physician reviewer found that the enrollee is able to check his blood sugar, draw up insulin and self-inject medication. The enrollee had no pain, no skin problems, no respiratory or cardiovascular issues. He was educated on diabetes medications. Skilled nursing services are not required to effectively provide treatment in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain his condition,or prevent deterioration. The enrollee has no complex wounds, can self-administer medication,and has been educated on disease/medication management. The services do not meet the definition of home health aide services as the documentation does not indicate that skilled nursing or therapy services are medically necessary, therefore, the request for home health aide services is not reasonable and necessary to the treatment of illness or injury by the skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met.Therefore, we decided that the Plan does not have to pre-approve home health nursing and aide visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient electroencephalogram (EEG). You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says previous EEG, MRI, and CT scans showed no acute abnormalities. The Plan follows Medicare rules. Medicare rules say ambulatory EEG monitoring is only covered under certain medical indications. 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 in this case, the enrollee has been referred to the epilepsy monitoring unit for evaluation of syncope vs. seizures vs. pseudoseizures. The enrollee has previously undergone EEGs in 2014 and 2016, and the studies both returned normal. He was more recently seen for evaluation after two more episodes and further work-up was recommended. It is noted that the enrollee has not recently had an EEG. According to the applicable LCD, an ambulatory EEG may be covered to differentiate between neurological and cardiac related problems. This would apply to this case as the provider's notes did raise the possibility of syncope. However, at the same time, the requested EEG monitoring would not need to be performed in the inpatient/acute hospital setting. The requested service, as ordered is not readily indicated to span two midnights. Nor is this service commonly and customarily performed in the acute care setting for enrollee's who do not have a prior history of epilepsy and/or significant medical comorbidities. The inpatient level of care would otherwise exceed the level of care that is necessary to provide adequate diagnostics and treatment to the member. In that regard the inpatient setting would not be 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 inpatient electroencephalogram (EEG).