Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower/tub for the enrollee.

You asked the Plan to pre-approve a walk-in shower/tub. You say that this is necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.

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 a walk-in shower/tub for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment (98940) provided on December 6, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the chiropractic services. You say that you expect that this claim would be reviewed and processed considering attached documents and considering the circumstances under which the services were rendered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment (98940) provided on December 6, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on May 19, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 97110 is not supported.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, there are no submitted records for the date of service at issue. 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 pay for the physical therapy services rendered on May 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 patient does not require treatment by multiple therapies and 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. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

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 patient does not require treatment by multiple therapies and 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.

You asked the Plan to pre-approve proton beam therapy. You say that proton beam therapy is medically necessary for the enrollee's diagnosis. The Plan denied your request. The Plan says the routine use of proton beam therapy is not accepted as a standard of care, and there is no documentation that standard radiotherapy would be insufficient.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve proton beam therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the use of proton therapy is an accepted radiation technology, that has proven efficacy and tolerability. Certain conditions- such as base of skull chordomas and chondrosarcomas, and pediatric central nervous system (CNS) malignancies are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. While small studies have demonstrated the ability of proton therapy to reduce lung and cardiac dose exposure, it is not clear if such reductions are clinically meaningful for proton therapy to be recommended for
general use. Thus, proton therapy is not investigational, but whether or not it is superior to non-proton based intensity-modulated radiation therapy (IMRT) for routine use is an investigational question. Routine use of proton therapy for breast cancer is not an accepted standard of care. IMRT that is photon based is designed to facilitate normal tissue sparing and could very readily be considered in this enrollee if a 3D plan is not acceptable, though typical forward planned 3D treatment is usually high effective and safe. While proton therapy can be used this case does not provide a plausible rationale for the need of proton therapy over conventional radiation and/or IMRT in 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 proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says rules for SNF care have not been met.
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 daily
skilled services are not necessary. Our physician reviewer found that the member has stabilized medically and
is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy
services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care.
Although further rehab services would be appropriate to improve function, as a practical matter, the
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member
does not have any parental medication, complex wound care, or nutrition given via a feeding tube. She is
medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or
near her baseline and he can receive services at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee's life could be in jeopardy if she goes home on her own. The Plan denied your request. The Plan says the enrollee does not meet The Centers for Medicare & Medicaid Services (CMS) guidelines for authorization, and is not considered medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee 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. Our physician reviewer also found that there is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 daily skilled services are not necessary. Our physician reviewer found that the member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of chronic medical problems. His physical function is at or near his baseline and he can receive services at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the professional services for the supervision of preparation and provision of antigens for allergen immunotherapy services coded 95165 provided on August 20, 2020 to August 21, 2020.
You asked the Plan to pay for the professional services for the supervision of preparation and provision of antigens for allergen immunotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 95165 is professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses).
We find that CPT code 95165 is not supported in the medical record. Specifically, the medical records submitted did not include documentation of antigen preparation/provision and the planned number of doses for the billed date of service. Based on this information, we decided that Medicare rules for coverage of the professional services for the supervision of preparation and provision of antigens for allergen immunotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the professional services for the supervision of preparation and provision of antigens for allergen immunotherapy services coded 95165 provided on August 20, 2020 to August 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires interdisciplinary therapy and close daily oversight by a physician in an inpatient setting. The Plan denied your request. The Plan says the enrollee does not have complex rehab 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 physician reviewer found that the enrollee was admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Her medical conditions are stable. There are no complex nursing needs. She does not require treatment by multiple therapies in an intensive rehabilitation therapy program. She does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. 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 heavy-duty hospital bed, extra wide, with a weight capacity greater than 350 pounds, but less than or equal to 600 pounds.
You asked the Plan to pre-approve a heavy-duty hospital bed. You say that the item 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 a hospital bed may be considered medically necessary when at least one of the following criteria is met: 1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an ordinary bed; or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to
congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have
been considered and ruled out; or
4. The patient requires traction equipment, which can only be attached to a hospital bed.
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 heavy duty hospital bed. Our reviewer
says that the item is not medically necessary. Our physician reviewer found the documentation does not clearly
reveal your 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 change in body position or special attachments that cannot be fixed on an ordinary bed. A
heavy duty, extra wide bed is not needed as the documentation indicates you are under 350 pounds. The request
for a semi-electric hospital bed is not medically necessary 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 a heavy duty hospital bed have not been met. Therefore, we decided that the
Plan does not have to pre-approve a heavy-duty hospital bed, extra wide, with a weight capacity greater than
350 pounds, but less than or equal to 600 pounds.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient does not require treatment by multiple therapies and 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. Specifically, medically necessary services are available at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 the inpatient hospital admission to be provided after upcoming knee surgery.
You asked the Plan to pre-approve inpatient hospital admission. You say that you told your doctor that you wanted to stay in the hospital to receive rehab after surgery. You do not want to go home the same day as surgery. Two days in the hospital is not unreasonable. The Plan denied your request. The Plan says the records do not show that there is a reasonable expectation that the enrollee will require medically needed hospital care spanning two midnights or longer.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for inpatient coverage are met in this case. Our physician reviewer found the enrollee appears to be obese but has no other notable risks which would suggest a likely prolonged recovery or higher risk of complication during the procedure to justify inpatient services. Based on the clinical documentation, the enrollee did not require hospitalization that would likely have crossed 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the inpatient hospital admission to be provided after upcoming knee surgery.