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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that it is felt that LTACH services are required. The Plan denied your request. The Plan says the criteria for coverage of LTACH care are not met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of Parkinson's disease, and chronic kidney disease. He was admitted to the acute care hospital on 4/20/2021 with pneumonia. The enrollee has chronic dysphagia with cachexia. The enrollee is bedbound at baseline and requires a Hoyer lift. On 4/27/21 it is documented that the family was deciding whether to consider palliative/hospice care versus placement of a feeding tube.

Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Kyphoplasty and Vertebroplasty

You asked the Plan to pre-approve Kyphoplasty and Vertebroplasty. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Kyphoplasty & Vertebroplasty are 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 Kyphoplasty and Vertebroplasty. Our reviewer says that the documentation supports that the requested services are medically reasonable and necessary. Our physician reviewer found you sustained a T12 vertebral body compression fracture which is greater than 25% height loss. You had a trial of Chiropractic therapy and over the counter analgesics. Your MRI shows a sub-acute fracture. You have failed conservative therapy, has a sub-acute fracture with substantial height loss. Therefore, you meet LCD 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 Kyphoplasty and Vertebroplasty have been met. Therefore, we decided that the Plan has to pre-approve Kyphoplasty and Vertebroplasty.

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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee has no complex medical needs that require intensive rehab.
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's current medical condition does not require intensive physician or nursing supervision in an IRF. The patient may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy can be tolerated on an intensive level in an IRF given documentation of patient's poor endurance and fatigue. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (K0861, E2359) and multiple accessories.
You asked the Plan to pre-approve a group 3 power wheelchair. You say that these items are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says although the enrollee has a neurologic condition appropriate for the group 3 power wheelchair, the member does not have a medical need for the multiple power options.
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power options 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 pre-approve a group 3 power wheelchair. Our reviewer says that a group 3 power wheelchair with multiple power options is not medically necessary and reasonable. Our physician reviewer found the patient has a mobility deficit that interferes with Mobility Related Activity of Daily Living (MRADL) participation in the home. The patient is noted to have failed all walking aids as she continues to fall and the devices do not offer stability. The patient is noted to be able to safely use the power wheelchair. The patient has amyotrophic lateral sclerosis (ALS) which is a neuromuscular disease appropriate for a Group 3 power wheelchair; however, the patient does not require multiple power options. The patient is not at high risk of developing a pressure ulcer, does not use intermittent catheterization for bladder management, or have spasticity therefore a power tilt and recline is not medically necessary. As a result, because the group 3 power wheelchair is not medically necessary the related accessories will not be 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 a group 3 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (K0861, E2359) and multiple accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite and endodontic therapy provided on November 17, 2020.

You asked the Plan to pay for the resin-based composite and endodontic therapy. You say that you would like these services to be covered up to the $1,000 dental benefit maximum.The Plan denied your request. The Plan says the treating provider opted out of Medicare effective January 18, 2016, to January 18, 2022. The Plan also says that charges incurred by Medicare opt out providers will not be reimbursed.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by a provider who has opted out of Medicare.Therefore, we decided that the Plan does not have to pay for the resin-based composite and endodontic therapy provided on November 17,
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection, onabotulinumtoxina, 1 unit (J0585).
You asked the Plan to pre-approve injection, onabotulinumtoxina, 1 unit (J0585). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says Botox is not indicated for treatment of the enrollee's condition.
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 injection, onabotulinumtoxina, 1 unit (J0585). Our reviewer says that the drug is not medically necessary. Our physician reviewer found as needed (PRN) use of Zofran resulted in substantial symptom benefit and improved diabetic control correlated with improved gastric emptying function. As such, the enrollee's gastroparesis is not medication-refractory. The medical necessity for nor appropriateness of intrapyloric botox injection has not been demonstrated by enrollee's available records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection, onabotulinumtoxina, 1 unit (J0585) have not been met. Therefore, we decided that the Plan does not have to pre-approve injection, onabotulinumtoxina, 1 unit (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion drug administration (99601, 99602)
provided on September 28, 2020, and October 29, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the CPT codes at issue have a status indicator
of I. The codes are not recognized by Medicare and will not be paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 99601 and 99602 are not supported in the medical record. Specifically, codes 99601
and 99602 have a status indicator of I and will not be paid by Medicare. These services should be reported with
a code that is recognized by Medicare. Based on this information, we decided that Medicare rules for coverage
of these codes have not been met. Therefore, we decided that the Plan does not have to pay for the home
infusion drug administration (99601, 99602) provided on September 28, 2020, and October 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. 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 must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the current acute care hospital with hemorrhagic stroke requiring surgery and mechanical ventilation support. Trach and percutaneous endoscopic gastrostomy (PEG) were placed but eventually the enrollee was extubated successfully after some improvement. Physical therapy was initiated and the enrollee is tolerating oral medicine according to recent notes. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom knee orthosis (L1844).
You asked the Plan to pre-approve a custom knee orthosis. You say that this orthosis is medically necessary. The Plan denied your request. The Plan says there is no evidence of documented knee instability and no evidence of recent significant injury to warrant the orthosis.
The Plan follows Medicare rules. Medicare rules say that it must be documented that a custom fabricated orthosis is medically necessary over a prefabricated orthosis. 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 custom knee orthosis. Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found you state you have some arthritis in the knee and suffered a bone bruise. Your provider recommended the brace to help the bone bruise heal and keep it from developing into something more serious. An x-ray of the right knee revealed: No acute osseous abnormality. Minimal joint effusion. There is no objective physical exam evidence that requires a custom fabricated orthosis instead of a prefabricated orthosis for reasons including deformity of the leg or knee, abnormal size of thigh and calf, or minimal muscle mass upon which to suspend an orthosis).
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 custom knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom knee orthosis (L1844).
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 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 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. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spine procedure.
You asked the Plan to pre-approve a spine procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a spine procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy of the procedure. 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 spine procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a spine procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz.
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 step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has moderate right knee pain. She has not tried and failed the Plan's required drugs of Orthovisc and Synvisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, the Supartz is not reasonable or medically necessary.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP device (E0601).

You asked the Plan to pre-approve a CPAP device. You say that the requested care is a necessity for you. The Plan denied your request. The Plan says rules for a CPAP device are not met.

The Plan must follow Medicare rules. Medicare rules say that continued coverage of a PAP device requires objective evidence of adherence to therapy, defined as use of PAP greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP device have not been met. Specifically, the reports of compliance with CPAP therapy provided in the case record do not document the use of PAP greater than or equal to 4 hours per night on 70% of nights. Therefore, we decided that the Plan does not have to pre-approve a CPAP device (E0601).
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 these services are medically necessary. The Plan denied your request. The Plan says that the clinical information indicates that the member's current needs can 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. 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's current medical condition does not require intensive physician or nursing supervision in an IRF. The patient may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation.

You asked the Plan to pre-approve SI joint radiofrequency ablation. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SI joint radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found cooled radiofrequency ablation is not covered by CMS. Radiofrequency ablation of the lateral branches is considered experimental/ investigational because of the wide variation in efficacy reported in the peer reviewed literature. The requested procedure is therefore considered not medically reasonable or 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 SI joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation.