Persius/hicric huggingface dataset:
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 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 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 concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to your fatigue and decreased endurance. Care at the skilled nursing facility level appears to be appropriate 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the optimizer cardiac contractility modulation device.

You asked the Plan to pre-approve the Optimizer Cardiac Contractility Modulation Device. You say that the services are medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of your health problem.

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 optimizer cardiac contractility modulation device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no current published guidelines from US professional societies to recommend the use of this device or routine use or specific appropriate indications for use at present. Given these issues with the current limited published data and lack of US guidelines for its use, and most especially, the additional fact that this patient is not currently on full optimal guideline directed medical management for her heart failure per AHA/ACC published guidelines (1), referral for Optimizer cardiac contractility modulation therapy would not be considered medically 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 Optimizer Cardiac Contractility Modulation Device have not been met. Therefore, we decided that the Plan does not have to pre-approve the optimizer cardiac contractility modulation device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam (92004) provided on November 11, 2020.

You asked the Plan to waive the copayment for the eye exam. You say that this charge is incorrect, and you should not be responsible for this payment. You feel it was billed with the wrong code.The Plan denied your request. The Plan says they verified the services with the provider and have already covered a routine eye exam for you in January with a $0 copayment. Only one routine eye exam can be covered at this cost each year, so your second eye exam falls into the other Medicare-covered eye examscategory, which requires a $50 copayment.

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 $50 copayment for all other Medicare-covered eye exams. 

You have been asked to pay a $50 copayment for an eye exam. The eye exam provided was not a screening and the Plan already paid for a routine eye exam for you in 2020. Therefore, this exam falls into the other Medicare-covered eye exams 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 copayment for the eye exam (92004) provided on November 11, 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 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 in the Medicare rules section. 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 with walking 200 feet mildly unsteady. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the blepharoplasty and brow ptosis repair to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are in-network providers available to perform surgery.

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 blepharoplasty and brow ptosis repair to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Bone marrow aspirate remains experimental in cases of spinal fusion. More research is needed to show safety and efficacy. Iliac crest bone graft is the gold standard. Our physician reviewer found that the enrollee's condition does not meet 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 bone marrow aspirate for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy (77336, 77332, 77263, 77290).
You asked the Plan to pre-approve proton beam therapy. You say that this is medically necessary. The Plan denied your request. The Plan says there is no benefit of proton beam therapy over intensity modulated radiation therapy.
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 proton beam therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling data to suggest that proton therapy is superior to or more beneficial than intensity modulated radiation therapy. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy (77336, 77332, 77263, 77290).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Onabotulinumtoxin A injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient evidence that any of the criteria for chronic migraine are met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the records are silent on headache frequency. The records do not support that the headaches cause significant disability. There is not sufficient documentation to support that the use of Botox would be clinically appropriate in this case. The records did not support the presence of chronic migraines--the only headache condition for which Botox is known to be effective.

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Onabotulinumtoxin A injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation that you will require a greater than 2 midnight stay.
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 hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. You are having an elective left shoulder arthroplasty after failing conservative treatments. You do not have a medical history which would expect a more complicated recovery or treatment plan for this low-risk procedure typically completed as an ambulatory surgical center. There is no expectation that you will require hospitalization that would cross 2 midnights. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital 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 these services are medically necessary. The Plan denied your request. The Plan says that your medical needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules 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. You appear to be more stable, but it is not clear if vent weaning is possible based on recent notes. Additional short-term acute care services and additional trials are needed to determine long-term needs. You do not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic resonance imaging (MRI).
You asked the Plan to pre-approve Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material (72148) and Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material (72146). You say that the enrollee needs spinal MRIs. The Plan denied your request. The Plan says there is no documentation supporting medical necessity for the MRIs.
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 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material (72148) and Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material (72146). Our reviewer says that the MRIs are not medically necessary. Our physician reviewer found there is no documentation from the ordering provider as to the medical scenario in this case. As such, the medical reasonableness and necessity of the requested services cannot be determined. The elements of the coverage criteria are not satisfied. the requested services cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material (72148) and Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material (72146) have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic resonance imaging (MRI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health stay.
You asked the Plan to pre-approve inpatient mental health stay. 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 inpatient psychiatric services may be covered if the patient requires active treatment. 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 mental health stay. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of April 27, 2021 forward and could have been treated in a lesser restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression. The enrollee was being cooperative and compliant while not showing any acute threats to safety. 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 mental health stay have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health stay.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a knee arthroplasty (27446).

You asked the Plan to pre-approve a knee arthroplasty. You say that the requested care is a medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested knee arthroplasty is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 knee arthroplasty. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is being treated for unilateral primary osteoarthritis of the right knee. Reasonable documentation is evident regarding a trial and failure of comprehensive, less invasive conservative care measures. Furthermore, despite imaging studies indicating tricompartmental pathology in the right knee; there is overwhelming degenerative erosion of the medial compartment (exponentially worse than the patellofemoral and lateral knee compartments). Despite the anterior cruciate ligament (ACL) degenerative signal, the ligament is not disrupted and the knee is overall stable to stress. A unicompartmental arthroplasty procedure is supported in such a clinical situation, and for such specific pathology as documented. There are circumstances noted to support the medical necessity of this request as a relative exception to guidelines.

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 knee arthroplasty have been met. Therefore, we decided that the Plan has to pre-approve a knee arthroplasty (27446).

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 that the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy but the documentation does not reveal that this therapy must be only on an intensive level 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 IRF admission and services.