Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.

You asked the Plan to pre-approve inpatient mental health treatment. 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 treatment. Our reviewer says that the services are not medically necessary.

Our physician reviewer found based upon review of the records provided, the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of July 24, 2021 forward. The enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. The enrollee was not showing any 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide sixteen (16) additional physical therapy (PT) visits.

You asked the Plan to provide the additional PT visits. You say that you are close to achieving your therapy goals and would like the Plan to cover additional visits. The Plan denied your request. The Plan says additional PT is not medically necessary per Medicare guidelines.

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 provide the additional PT visits.

Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found in this case, the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition and therefore are not 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 the additional PT visits have not been met. Therefore, we decided that the Plan does not have to provide sixteen (16) additional physical therapy (PT) visits.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.

You asked the Plan to pre-approve SNF care. You say that these services are medically necessary for the enrollee. The Plan denied your request. The Plan says that that the member is at a functional level, she does not meet Medicare criteria for SNF level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 SNF care. Our reviewer says that SNF care is medically reasonable and necessary for the enrollee. The enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee's weight bearing status was recently advanced. A period of skilled therapy is reasonable to improve strength and endurance, while assessing safety and mechanics. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee's condition meets Medicare criteria for SNF 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Novolog.

You asked the Plan to pre-approve a tier exception for Novolog. You say that the exception is needed. The Plan denied your request. The Plan says the drug does not qualify for tier exceptions.

The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Novolog have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Novolog.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants.

You asked the Plan to pre-approve dental implants. You say that getting the implants is medically necessary for you to be able to eat properly. You say that the letter from your primary care physician advises the implants are medically necessary. The Plan denied your request. The Plan says the services are not covered benefits.

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.
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Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental implants.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy sessions.

You asked the Plan to pre-approve additional physical therapy sessions. You say that the requested services should be covered because your right knee is not better yet and still needs more physical therapy. The Plan denied your request. The Plan says rules for physical therapy have not been met because the requested services are not medically necessary.

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 additional physical therapy sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you have previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of your medical condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy sessions.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve continued home health occupational therapy services.

You asked the Plan to pre-approve home health services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing coverage of home care services. There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services at issue in this appeal. Therefore, we decided that the Plan has to pre-approve continued home health occupational therapy 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Denosumab.

You asked the Plan to pre-approve Denosumab. You say that the medication is 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 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 Denosumab. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the Denosumab is medically reasonable or necessary for you. The documentation does not support that the Denosumab is safe and effective for you. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Denosumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Denosumab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services were medically necessary. The Plan denied your request. The Plan says that there is no documentation indicating the facility attempted to notify plan of member's admission.

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 hospital services.

Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. You did not appear to require inpatient mental health treatment as you were not a danger to yourself or others and were cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric 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 psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital 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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that a week or two of therapy will benefit the member. The Plan denied your request. The Plan says that the enrollee's current needs can be addressed at a lower level of care.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The patient was admitted for 3 vessel coronary artery bypass grafting. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for additional SNF care provided on January 17 to February 15, 2021.

You asked the Plan to pay for SNF care. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met because the level of care was 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 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 pay for SNF care. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found that, during the dates in question, there were no identifiable skilled nursing service nor skilled therapy service needs. The enrollee did 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for additional SNF care provided on January 17 to February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre sensor and reader (CPT code K0554 and K0553), for the enrollee.

You asked the Plan to pre-approve the items. You say that the enrollee has Type 2 Diabetes Mellitus, not urging CGM therapy, is using Toujeo once daily, does not need to make frequent adjustments in their insulin based on their blood sugar levels and the enrollee did have an in-person visit within six (6) months of prescribing CGM therapy to assess their diabetes. The Plan denied your request. The Plan says the items are not necessary.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. Review of the file shows that the enrollee is using insulin once daily, they do not need to make frequent adjustments in their insulin regimen based on their blood sugar levels. Based on this information, we decided that Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre sensor and reader (CPT code K0554 and K0553), for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the angioplasty without stenting (CPT code(s): 37233 and 37229), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this vascular intervention is medically necessary for re-vascularization to be performed in order to save the enrollee's limb. The Plan denied your request. The Plan says that the requested angioplasty without stenting (CPT code(s): 37229 and 37233) will not be done on the iliac, femoral, or popliteal artery, which is non-covered per the NCD.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our physician reviewer found the documentation supports the medical necessity of the treatments in question. It is unclear why angioplasty with stenting would be covered but angioplasty without stenting wouldn't. In this case, however, the enrollee has a limb threatening condition that appears to be worsening. While a literal interpretation of the criteria would exclude tibial angioplasty from coverage, in this case there is no time to re-appeal based on medical necessity. Tibial angioplasty is a well described and commonly performed procedure to restore perfusion for patients with limb threatening ischemia. This enrollee has documented distal gangrene, status post forefoot amputation and has evidence of deterioration on follow-up. Recommend coverage without delay. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have been met. Therefore, we decided that the Plan has to pre-approve the angioplasty without stenting (CPT code(s): 37233 and 37229), 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional prosthetic equipment (L5781, L5988, L5984, L5910).

You asked the Plan to pre-approve additional prosthetic equipment. You say that these items are medically necessary. The Plan denied your request. The Plan says no medical need for the requested prosthetic equipment beyond what was already approved.

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 additional prosthetic equipment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 35-year-old male with a past medical history of chronic left lower extremity wounds and a left below-the-knee amputation who requires a new lower extremity prosthesis. Based on the medical records provided there is no documentation that the prosthetic accessories at issue in this case are medically reasonable and necessary. The available medical records do not document necessity of the requested L5910 or for additions of L5781, L5988, and L5984. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional prosthetic equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve additional prosthetic equipment (L5781, L5988, L5984, L5910).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services, 2 hours per day, 3 days per week for 9 weeks.
You asked the Plan to pre-approve a home health aide. You say that your physical and mental health will be affected significantly without home health aide services. You say that you have injuries that preventive you from being able to provide daily tasks for yourself. You also say that the home health aide assists you with pharmacy and grocery shopping trips and meal preparation. The Plan denied your request. The Plan says the provided documentation shows that you are independent with personal care tasks. The Plan says that the requested home health aide services are not medically necessary. The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 a home health aide. Our reviewer says that the home health aide services are not medically necessary. Our physician reviewer found the documentation doesn't support that you require skilled nursing services or skilled therapy services to provide treatment that is medically necessary. The reviewer found that you do not require skilled nursing or therapy 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. The reviewer also found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the reviewer found that requested home health aide services are not 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 a home health aide have not been met. Specifically, the record shows that you do not require any skilled services. Therefore, we decided that the Plan does not have to pre-approve home health aide services, 2 hours per day, 3 days per week for 9 weeks.