Persius/hicric huggingface dataset:
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 this is medically necessary. The Plan denied your request. The Plan says you are receiving appropriate care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 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 you need IRF care. 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 you have a past medical history of arachnoid cyst and thoracic myelopathy status post laminectomy who is living at home with ongoing weakness. Medical problems are stable. There are no
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because admission to the IRF is medically necessary. The Plan denied your request. The Plan says the records do not show that you need an intensive program with a team of health care professionals and doctors that specialize in complex medical needs.
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 are no complex nursing or rehabilitation 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 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 portable oxygen concentrator (POC).
You asked the Plan to pre-approve the requested POC. You say that you wish to be approved for a POC due to difficulty with the weight of your portable tanks. The Plan denied your request. The Plan says there is no documentation that you are not able to use the portable tanks in the home. There are also smaller tanks and liquid oxygen that could be approved which would be easier to carry with you. The medical necessity for a POC is not established.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. DME is also only covered for use in the home. The file shows that you have a stationary oxygen system with portable tanks. There is some indication that the portable tanks are too heavy for you. However, the medical records from your provider do not document these issues. There is no direct evidence that the portable tanks do not meet your needs within the home. The Plan
has also indicated that there are smaller/less bulky tank options that can be tried if requested. Based on the information provided, we find that the POC would serve the same purpose as the portable tanks you have been provided for use in the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Cologuard test.
You asked the Plan to pre-approve the Cologuard testing. You say that it is felt that this lab screening is necessary since the enrollee is not recommended to undergo anesthesia for a standard colonoscopy. The Plan denied your request. The Plan says the criteria for coverage for this testing are not met.
The Plan must follow Medicare rules. Medicare rules say that Cologuard testing is covered only for enrollees between 50 and 85 years of age who are asymptomatic. In this case, the enrollee is 86 years old and had a recent positive FIT result. This means that the Medicare criteria for coverage of this test have not been met. Therefore, we decided that the Plan does not have to pre-approve the Cologuard test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-electric hospital bed, with any type side rails, with mattress (E0260).
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the request for the semi electric hospital bed does not meet medical necessity criteria.
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 semi-electric hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not clearly reveal that the enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent, or an immediate need to change body position or special attachments that cannot be fixed on an ordinary bed are required. The request for a semi-electric hospital bed is not medically necessary for this enrollee. 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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve the semi-electric hospital bed, with any type side rails, with mattress (E0260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete maxillary denture (D5110) and complete mandibular denture (D5120).
You asked the Plan to pre-approve complete maxillary denture and complete mandibular denture. You say that you need to get your dentures replaced. The Plan denied your request. The Plan says the benefit for this service has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers complete maxillary denture and complete mandibular denture once every five years. We looked at the file and Medicare rules. The file indicates that you last received dentures in July 2020. Therefore, your benefit has been exhausted at this time. Based on this information, we decided that the Plan's rules for coverage of complete maxillary denture and complete mandibular denture have not been met. Therefore, we decided that the Plan does not have to pre-approve complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT)(E0766).

You asked the Plan to pre-approve the TTFT. You say that the enrollee requires the therapy. The Plan denied your request. The Plan says the clinical information provided shows you have recurrent (not newly diagnosed) brain cancer (Glioblastoma Multiforme or GBM), so it is not covered.

The Plan follows Medicare rules. Medicare rules say that TTFT is not reasonable or necessary for the treatment of recurrent GBM. 

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 TTFT. Our reviewer says that the service is not medically necessary. Our physician reviewer found the service is not reasonable or medically necessary for recurrent disease. 

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 TTFT have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT)(E0766).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis with adjustable flexion and extension joint (L1843).
You asked the Plan to pre-approve knee orthosis. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because the records do not show that the enrollee has had a recent injury, surgery, or objective evidence of knee instability.
The Plan follows Medicare rules. Medicare rules say that a knee orthosis such as L1843 may be covered for enrollees that have had a recent injury to, or surgical procedure on, the knee(s) or who have documented knee instability due to certain conditions. 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 knee orthosis. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested knee orthosis. Our physician reviewer found the documentation does not support that the enrollee has had a recent injury to or surgical procedure on the knee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis with adjustable flexion and extension joint (L1843).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that bisphosphonates are contraindicated for the enrollee
due to GERD and reflux diagnoses. The Plan denied your request. The Plan says the enrollee does not show to
have a history of osteoporotic fracture or has a contraindication to zoledronic acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Prolia. Our reviewer says that the
criteria for coverage have not been met. Our physician reviewer found that the Plan requires an osteoporosisrelated
fracture or a trial of drug zoledronic acid before they will approve the requested drug. In this case, the
records do not show the enrollee has an osteoporosis-related fracture. There is no documentation provided
indicating that she tried and failed the required drug(s). There is no documentation provided indicating that the
Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Keytruda 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 this is not medically necessary.
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 drug is not medically reasonable or necessary. Our physician reviewer found that as the enrollee has microsatellite stability, the drug cannot be approved. 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 a Keytruda injection for the enrollee.
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 a SNF admission. You say that you need SNF services. The Plan denied your request. The Plan says you do not require the daily skilled therapy or nursing services of a SNF
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 a SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does 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 a SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (CPT 93971) provided to the enrollee on November 30, 2020.
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The Plan says there is a missing/incomplete/invalid diagnosis or condition.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 93971 is "duplex scan of extremity veins including responses to compression and other maneuvers." We asked our coding 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 the scan. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found CPT 93971 was submitted to the health plan with a primary diagnosis of I26.90. Diagnosis code I26.9 requires an appropriate primary diagnosis code when billing to the health plan. ICD-10 Coding Guidelines state, "Code first underlying infection" for Dx code I26.9. Since 93971 was not submitted with an appropriate primary diagnosis code, this service is not eligible for reimbursement consideration. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pay for a duplex scan (CPT 93971) provided to the enrollee on November 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
You asked the Plan to pre-approve the Vertiflex device. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says Vertiflex is investigational and the member is not receiving this procedure as a part of a clinical trial.
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 Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental and more research is needed to show its safety and efficacy. 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient partial mastectomy with a tertiary care
provider.
You asked the Plan to pre-approve outpatient surgery with a tertiary level of care provider. You say that the
requested tertiary level of care is medically necessary. The Plan denied your request. The Plan says the
requested tertiary level of care is not medically necessary. Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you
must use contract providers for care.
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 outpatient surgery with a tertiary level
of care provider. Our reviewer says that the requested tertiary level of care is not medically necessary. Our
physician reviewer found the enrollee is diagnosed with left breast low grade adeno-squamous carcinoma, 0.6
cm in greatest dimension. The requested procedure is for a partial mastectomy which was approved by the Plan
with referral to a participating primary network provider.
The requested tertiary level of care is not needed in this case. The requested surgery can be done by a nontertiary
provider. There is nothing unique warranting tertiary 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 outpatient surgery with a tertiary level of care provider have not been met.
Therefore, we decided that the Plan does not have to pre-approve an outpatient partial mastectomy with a
tertiary care provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because
admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the records
received do not support that the member will require special long term acute care available at a LTACH.
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 requested LTACH services are able to be furnished safely and effectively only on
an inpatient 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.