Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services (skilled nursing, physical therapy,
and occupational therapy visits).
You asked the Plan to pre-approve the requested home health services. You say that the enrollee needs wound
care three times weekly and should be approved for all home health services requested. The Plan denied your
request. The Plan says there is no documentation of the need for skilled services in the home.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 requested home health services. Our
reviewer says that the requested home health services are not considered reasonable and necessary based on
Medicare rules. Our physician reviewer found the records do not show that skilled nursing services ( 3 x per
week) are required to effectively provide treatment, care, and/or services in order to improve the patient's
condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent
deterioration. The patient's medical conditions are stable. The wound she has does not require complex SN
care. There are no detailed wound measurements. There is no evidence of wound infection. The documentation
does not reveal functional deficits that indicate skilled therapy is needed to effectively provide treatment, care,
and/or services in order to improve the patient's level of function, or to establish/perform a maintenance
program to maintain the patient's level of function and/or prevent deterioration. The patient's functional level
does not require ongoing skilled therapy. As the patient does not require skilled therapy or skilled nursing
services the patient does not meet the definition of home health aide services per Section 50.2 and the request
for home health aide services are not reasonable and necessary to the treatment of the patient's illness or injury
by the skilled professional staff.
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 requested home health services have not been met. Therefore, we decided
that the Plan does not have to pre-approve home health services (skilled nursing, physical therapy, and
occupational therapy visits).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total knee arthroplasty (TKA) surgery.
You asked the Plan to pre-approve knee surgery. You say that you are appealing. The Plan denied your request.
The Plan says the denial of authorization for this service is correct, because the documentation submitted does
not support the medical necessity of this surgery.
The Plan follows Medicare rules. Medicare rules say that TKA surgery is considered medically reasonable and
necessary when 3 or more of the previously listed criteria have been 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 knee surgery. Our reviewer says that
the enrollee does not meet the Medicare criteria for the requested TKA surgery. Our physician reviewer found
the medical records do not show advanced knee degenerative joint disease (DJD), unsuccessful appropriate
conservative therapy measures, distinct structural abnormalities, or failed previous joint replacement.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of knee surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve total knee arthroplasty (TKA) surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (64625).
You asked the Plan to pre-approve radiofrequency ablation. You say that this has helped the enrollee in the past. The Plan denied your request. The Plan says this is experimental.
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 radiofrequency ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found radiofrequency ablation for the treatment of low back pain has not been consistently shown to provide additional lasting benefit when added to a treatment regimen of conservative measures. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.
You asked the Plan to pre-approve hearing aids. You say that you're in pain due to a past gunshot injury and your specialist and surgeon recommended testing hearing aids as a possible solution to minimize pain, instead of having surgery. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the hearing aids.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when there is a signed prescription from an otolaryngologist (ENT - ear nose and throat doctor) or the attending physician, a signed examination of your ear, nose and throat, and lastly, a signed audiological (hearing) report and hearing aid evaluation. 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 hearing aids. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was diagnosed with mild conductive hearing loss on the right and advised to have a hearing aid placed on the right. In general, a hearing aid is not indicated for mild hearing loss. It is difficult to determine if there is another reason a hearing aid was recommended without an audiogram. There is no description of his PTA, SRT or WRS to determine if he has difficulty with speech and conversation. Hearing aids can be helpful for tinnitus, but in that case he would benefit from bilateral hearing aids. There is no discussion about management strategies utilized for his tinnitus, which would be the first step in treatment. Hearing aids are not indicated for ear pain. Therefore, a hearing aid is not medically reasonable or necessary in this case. We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
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 based on the documentation provided, the health plan's denial of LTACH coverage
should be upheld. The patient is currently undergoing treatment at an ACH for CHF. 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 LTC 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis.
You asked the Plan to pre-approve the Restasis. You say that the enrollee has had therapeutic failures to alternative drugs. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Restasis.
Benefits for the Restasis may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a SNF.
You asked the Plan to pre-approve the SNF admission. You say that the enrollee has many needs that you are not able to continue helping her with at home. The Plan denied your request. The Plan says custodial care is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF admission. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a SNF.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF care.
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 above.
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 records do not indicate that there are significant, or complex medical/nursing
issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication
management, wound care, and daily therapy can be provided at a SNF. It is not clear the member would be able
to fully benefit and/or participate in an IRF 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 IRF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that continued therapy would be beneficial. The Plan denied your request. The Plan says additional physical therapy is 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 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 that you had extensive therapy and were trained in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing 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 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. The Plan denied your request. The Plan says continued therapy is 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 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 that the enrollee has had extensive therapy and was trained in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing 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 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records received do not document an inadequate response to, or intolerance to one oral bisphosphonate, and intravenous biphosphonate, or a creatinine clearance less than 35 ml/minute.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found in this case, the medical records received do not document an inadequate response to, or intolerance to one oral bisphosphonate and intravenous biphosphonate, or a creatinine clearance less than 35 ml/minute. The review has determined that the patient has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are 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 facet joint injections. Our reviewer says that the documentation does not support that the requested facet joint injections are medically reasonable or necessary. Our physician reviewer found the enrollee has a history of low back pain which had both axial and radicular features. On exam, the enrollee had a positive straight leg test suggestive of a radicular process. Given that some of the enrollee's pain appears to be associated with a radicular process. In that setting, it does not appear that the criteria for coverage have otherwise been satisfied in this case. Therefore, the enrollee does not meet criteria for the requested 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
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 admission. You say that the enrollee needs a different kind of treatment that the IRF is unable to provide. The Plan denied your request. The Plan says the denial of authorization for transfer to SNF is correct, because the enrollee's needs can be met in the current inpatient rehabilitation facility setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and has been receiving care at an inpatient rehabilitation facility. He does require skilled nursing and/or skilled therapy services on a daily basis; however, he is medically stable and can continue to receive further rehab services at the inpatient rehabilitation facility. There is no documentation to support that the IRF cannot provide the care the enrollee requires. The skilled care does not have to be accomplished in a SNF.
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 admission 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: Home Health
Decision: Partially Favorable

We decided that the Plan has to approve home health services through August 20, 2020. We decided that the Plan does not have to approve home health services after August 20, 2020.
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan says that the services are not medically necessary.
We decided that the Plan has to approve home health services through August 20, 2020.
The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing coverage of home care services.
Review of the file shows that the NOMNC was not signed until August 18, 2020. The Plan must approve continued services until two days after the NOMNC has a valid signature. Therefore, we decided that the Plan has to approve home health services through August 20, 2020.
We also decided that the Plan does not have to approve home health services after August 20, 2020.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 continued services beyond April 20, 2020 are not medically necessary. Our physician reviewer found the submitted records show that you have been receiving home health services since April 5, 2020. The most recent therapy notes show that are able to independently bathe yourself and dress without assistance You need supervision with toileting, transfers, and ambulation but are independent with bed mobility. The records do not support that continued services are required to effectively provide treatment, care, and/or services to improve your condition. You do not need a maintenance program to maintain your condition or prevent deterioration. The records do not show that you have any skilled needs beyond the approved dates at this time. 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 approve home health services after August 20, 2020.
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.