Persius/hicric huggingface dataset:
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 the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.

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 admission to a LTACH is not medically necessary. Our physician reviewer found based on
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH).
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the services can be provided by an in-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 must 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 physician's services to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).

You asked the Plan to pre-approve the spacer placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.

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 spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the interspinous spacer device is experimental. More research is needed to show 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 spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-spinal bone growth (osteogenesis) stimulator.

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. Medicare rules say that a bone growth stimulator is covered when specific criteria are met. 

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 fractured ankle. The records do not contain an x-ray showing no healing of this fracture after 90 days of standard treatment. The criteria for coverage are not met; therefore, the bone growth stimulator is 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 non-spinal bone growth (osteogenesis) stimulator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.

You asked the Plan to pre-approve HBO therapy. 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 follows Medicare rules. Medicare rules say that HBO therapy will be covered when specific criteria is
met.

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 HBO therapy. Our reviewer says that
the services are not medically necessary. Our physician reviewer found in this case; the enrollee has not failed
an adequate course of standard wound therapy. The wound is not Wagner grade III or higher. The elements of
the national coverage determination are not satisfied. The requested service 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 HBO therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).

You asked the Plan to pre-approve the portable oxygen concentrator. You say that the portable concentrator is medically necessary. The Plan denied your request. The Plan says this equipment is for use outside the home and is not covered.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home.

Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).

You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective and is
medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization
for this service is correct, because this procedure is experimental/investigational.

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 Vertiflex. 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, 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have
to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.

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 insertion of a Superion interspinous stabilization device (22869).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care.

You asked the Plan to pre-approve inpatient psychiatric care. You say that this service continues to be medically necessary. The Plan denied your request. The Plan says inpatient psychiatric care is no longer 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 inpatient psychiatric care. Our reviewer says that the request for inpatient care from April 25, 2021, forward is not medically necessary and reasonable. Our physician reviewer found this 78-year-old male was admitted to the acute inpatient psychiatric hospitalization on April 9, 2021, and the Plan covered this care until April 24, 2021. Based upon a review of the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of April 25, 2021. The enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. Therefore, it appears that care can be provided in a less restrictive 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 inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 appears to be improving and only requires additional short-term acute care services for additional weaning and care which can safely be received at the current acute care facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed.

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.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).

You asked the Plan to pre-approve Gel-One. You say that the drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says step therapy criteria has not been met.

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 Gel-One. Our reviewer says that the
requested drug is not medically reasonable and necessary. Our physician reviewer found the review indicates
that the enrollee is a 73-year-old male with osteoarthritis of the knee whose provider has requested Gel-One.
The Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. In this case,
the patient has not 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 Gel-One have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gel-One (J7326).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve post removal for tooth #13 (D2955).

You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services (D2955) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve post removal for tooth #13 (D2955).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laminectomy, fusion, autograft, and insertion of a
stabilizing device (spinal surgery services).

You asked the Plan to pre-approve spinal surgery. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says the denial of authorization for these services is correct, because it has
not been demonstrated that the enrollee is nicotine-free or has undergone appropriate conservative 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 spinal surgery. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found appropriate conservative treatment measures have not been documented to include a recent and
adequate trial of physical therapy for back pain. More conservative measures are needed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve laminectomy, fusion, autograft, and insertion of a stabilizing device (spinal surgery
services).
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 you appear to be improving and only requires additional short-term acute care services which can safely be received at the current acute care facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Therefore, this request for LTACH will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed.

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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult washcloth wipes (A9286).

You asked the Plan to pre-approve the wupes. You say that this is medically necessary. The Plan denied your request. The Plan says this is a coverage exclusion.

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 adult washcloth wipes (A9286).