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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. The 
patient is medically stable with no evidence of need for supervision by physical medicine and rehab physician. 
Functionally given his current level, he is not expected to make a significant progress in a predicted (7-10 days) 
period of time. The patient may benefit from further physical therapy and occupational therapy but does not 
require an intensive therapy program. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Stelara for the enrollee.
You asked the Plan to pre-approve a tier exception. You say that the enrollee has been stable on this medication
for three years. The Plan denied your request. The Plan says that tier exceptions are not available for drugs
covered by Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D
drugs.
The requested drug is covered under Part B. Therefore, we decided that the Plan does not have to pre-approve a
tier exception for Stelara for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with an expandable controller with related electronic connection and harness.
You asked the Plan to pre-approve the Group 3 PWC with expandable controller. You say that the requested items are medically necessary and should be approved. The Plan denied your request. The Plan says an approval was granted for a Group 2 PWC instead of a Group 3 because the enrollee does not have a condition for which Group 3 is covered by Medicare. In addition, the expandable controller is denied due to lack of medical need.
The Plan must follow Medicare rules. Medicare rules say that Group 3 PWC are only covered for enrollees with a mobility deficit caused by one of the above noted conditions. The rules also indicate that an expandable controller allows for control of other power seating systems through the drive control but that power tilt/recline feature has its own switch. We looked at the file and Medicare rules. The record does not show that your mobility deficit is due to a neurological condition, myopathy, or congenital skeletal deformity. The records also do not clearly indicate that you are unable to use the individual switches for the power seating features on a Group 2 PWC. Based on this information, we decided that Medicare rules for coverage of the Group 3 PWC with expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with an expandable controller with related electronic connection and harness.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three additional skilled nursing home health visits.
You asked the Plan to pre-approve the additional visits. 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. 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 the additional visits. Our reviewer says that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found in order to require home health care skilled services, you must be confined to the home, under the care of a physician, and receiving services under a plan of care established and periodically reviewed by a physician. You do not require skilled nursing services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain your condition and/or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve three additional skilled nursing home health visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee. 
 
You asked the Plan to pre-approve the bed. 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. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 bed. Our reviewer says that the 
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not support that requested semi-electrical hospital bed is medically necessary. In order to qualify for a semi-
electric hospital bed, the enrollee's condition must require frequent change in body position and/or there may be 
an immediate need for a change in body position (i.e., no delay can be tolerated). With the enrollee's dementia, 
it is not expected that the enrollee could operate the controls and the adjustments. Elevation of the head/upper 
body less than 30 degrees does not usually require the use of a hospital bed. 
 
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 bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for dental extractions provided by an out-of-network provider on March 10, 2020.
You asked the Plan to waive the copayment for the dental extractions. You say that you would like reconsideration because you were told these services would be entirely covered. The Plan denied your request. The Plan says the correct cost sharing was applied to these services.
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% coinsurance for out-of-network dental services. You have been asked to pay a 50% coinsurance for the dental extractions. The dental extractions fall within the out-of-network dental services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for dental extractions provided by an out-of-network provider on March 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
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 home health services to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says that home health has already been arranged through the Medicaid benefit. 
 
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 reviewer 
says that the requested services are medically reasonable and necessary. Our physician reviewer found in this 
case, the documentation supports that you require skilled nursing services or skilled rehab services to provide 
treatment that is medically necessary. You do require skilled nursing or rehab services to effectively provide 
treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain 
your condition and/or prevent deterioration. You require assistance with your medications and general 
cardiopulmonary monitoring. You have had multiple emergency room visits in the past 6 months. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve home health services.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LINX procedure.
You asked the Plan to pre-approve a LINX procedure. 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 a LINX procedure. Our reviewer says that the requested LINX procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found that there was no documentation provided that demonstrates objective correlation of enrollee's symptoms with acid reflux events--e.g. no pH study was provided. Further, the enrollee has a normal LES that does not require surgical augmentation based on available records. The available records document that enrollee has elected to take no acid blocker therapy. There is no provided evidence that acid reducer medications were ineffective nor that she found them intolerable. As such, the enrollee cannot be considered to have medication-refractory gastroesophageal reflux. Medical necessity is not demonstrated by the enrollee's provided medical record for either antireflux surgery or the LINX procedure. 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 LINX procedure have not been met. It should be noted that the LCD referenced by the Plan has been retired and is no longer applicable to this appeal. Therefore, we decided that the Plan does not have to pre-approve a LINX procedure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a coronary computed tomography (CT) scan with
quantitative evaluation of coronary calcium.
You asked the Plan to pre-approve these services. You say that you are trying to figure out your heart issues.
The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you have a
history of heart issues, including rapid heartbeat (paroxysmal atrial fibrillation) and possible congestive heart
failure. The submitted medical evaluation is limited, but it appears that the requested coronary CT is being
requested for screening for underlying coronary artery disease. There is no documentation of elevated cardiac
risk for coronary artery disease. The CT scan is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a coronary computed tomography (CT) scan with quantitative evaluation of coronary
calcium.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has weakness from a neck injury. 
The Plan denied your request. The Plan says the admission is not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
with acute respiratory failure, altered mental status, hypotension, and sepsis. The records show that he has 
returned to near his baseline level of function and no significant improvement is expected. He does not require 
skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the 
necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services beginning July 6, 2020.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on July 1, 2020 with major neurocognitive disorder with behavioral disturbance, Alzheimer's type. Based on the submitted records, it is not expected that he will improve in a reasonable period of time beyond the dates in question, as he is not showing any dangerousness to self or others and has no hallucinations or abnormal behaviors. He is compliant with treatment and is not showing any aggressive behaviors. It does not appear that active treatment is taking place. The continued inpatient psychiatric services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services beginning July 6, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve speech therapy services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the information reviewed did not meet the criteria for speech therapy services.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are medically reasonable or necessary. Our physician reviewer found the records demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist. he requested services are not part of a maintenance program, the specialized skill, knowledge and judgment of a qualified therapist are required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. The literature clearly supports that LSVT improves the speech in Parkinson's disease patients. The enrollee also needs to work swallowing to prevent aspiration and its consequences. 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 speech therapy services for the enrollee.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast (77049).
You asked the Plan to pre-approve an MRI. You say that this is medically necessary. The Plan denied your request. The Plan says this is a screening test.
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 an MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found per the NCCN Guidelines for Invasive Breast Cancer, routine imaging of reconstructed breast is not indicated. The guidelines recommend an annual mammogram for follow-up imaging. The submitted documentation does not indicate the enrollee has had an abnormal mammogram or a suspicious area on physical exam. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast (77049).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services for a consultation. 
 
You asked the Plan to pre-approve the physician's services for a consultation. You say that you have hemorrhoids and would like laser treatment. The Plan denied your request. The Plan says you must receive care from in-network providers. You will only be referred to a doctor outside of the Plan's medical group if the Plan's specialists cannot provide the care you need. The Plan also says the requested provider does not perform the laser procedure and it is also not the standard of care for hemorrhoid removal. 
 
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services for a consultation.