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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 enrollee was admitted for cellulitis. The enrollee's medical problems are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond March 19, 2021.
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 continued services are 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 pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the SNF on February 11, 2021. The physical therapy note dated March 18, 2021 states you need minimal assistance to walk 225 feet. You need varied assistance with activities of daily living, including bathing, dressing, eating, and grooming. You have no skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond March 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve Botox. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested Botox is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain indications. 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 Botox. Our reviewer says that the documentation does not support that the requested Botox is medically reasonable or necessary. Our physician reviewer found you have complaints of episodic sweating of the head (scalp), neck and also to the face of some extent. You do not report feeling hot at the time of sweating. The documentation shows that you have had this for many years but it has become particularly bad in the past six months. The only approved therapeutic indication in the Botox package insert for hyperhidrosis is for severe axillary hyperhidrosis. The documentation does not support that you meet the LCD criteria for Botox. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2387)
provided September 14, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were
medically necessary. The Plan denied your request. The Plan says there is no evidence that the prescribing
physician ever saw the member.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to
the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our
reviewer says that the requested items were not medically necessary and reasonable. Our physician reviewer
found there is insufficient documentation of an evaluation of the enrollee, and there is insufficient credible
objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable
when the base item is not covered.
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 knee orthosis and suspension sleeve have not been met. Therefore, we
decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2387)
provided September 14, 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 will receive the appropriate level of care in the acute rehabilitation setting. The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting 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 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. 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. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer procedure.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the enrollee needs this procedure for pain relief. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and 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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). 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 for use in spinal surgery. More research is needed to show safety and efficacy of the device. Open laminectomy is the gold standard procedure for spinal stenosis treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair with multiple power options and accessories for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a request for a power mobility device with no power options can be reviewed if submitted.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the requested K0861 with multiple power options exceeds the enrollee's medical needs. The documentation does not reveal that the patient needs is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. The documentation does not support that it is medically necessary to control the requested power options through the joystick (drive interface). The documentation does not support that it is medically necessary to control the requested power options through the joystick (drive interface). The enrollee's strength and functional ability with independence in eating and grooming should be sufficient to control any power options through their own switches. The documentation does not reveal that tilt and recline are medically necessary therefore the request for Group 3 power wheelchair with multiple power options is not medically necessary per Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792) and Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair with multiple power options and accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided August 17, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the orthosis provided was medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence the prescribing physician ever saw the member.
The Plan follows Medicare rules. Medicare rules say that coverage of a spinal orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided August 17, 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 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 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. You were admitted for sepsis, urinary tract infection and acute kidney injury. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 14, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the requested orthosis was medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence prescribing physician ever saw the member.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to coverage criteria as listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-spinal orthosis have been met. The documentation does not support
that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a credible evaluation and a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services.

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 49905 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 49905 is omental flap, intra-abdominal (List separately in addition to code for primary procedure).

We find that CPT code 49905 is not supported in the medical record. Specifically, there is no documentation of an omental flap to repair an intra-abdominal defect. 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 surgical services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve removal of residual tooth roots. We decided that the Plan does not have to pre-approve the removal of torus palatinus and lateral exostosis.

You asked the Plan to pre-approve removal of residual tooth roots. The Plan says that the services are not a covered benefit.

We decided that the Plan has to pre-approve the removal of residual tooth roots.

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.

We looked at the file, and Medicare rules. The benefits show that the Plan offers a dental benefit in excess of Medicare coverage, which includes the removal of residual tooth roots. Based on this information, we decided that the Plan's rules for coverage have been met. Therefore, we decided that the Plan has to pre-approve the removal of residual tooth roots.

We also decided that the Plan does not have to pre-approve the removal of torus palatinus and lateral exostosis.

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.

Although the Plan offers a dental benefit in excess of Medicare coverage, these requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the removal of torus palatinus and lateral exostosis.

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: 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 enrollee needs this care to be able to walk again. The Plan denied your request. The Plan says the enrollee's needs could be met 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. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for altered mental status and falls. Medical problems 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. 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 this patient 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.