Persius/hicric huggingface dataset:
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there are no skilled needs identified.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on November 6, 2020.

You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.

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 did not pre-approve the psychotherapy services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on
November 6, 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 it is felt that this enrollee is a good candidate for the IRF level of care. The Plan denied your request. The Plan says the requested IRF care is not medically necessary for this enrollee.
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 is an 83-year-old man with a history of heart disease, chronic obstructive pulmonary disease, and hypertension who presented to the medical center on 4/17/21 with alcohol intoxication. He has been diagnosed with alcoholic polyneuropathy. Physical therapy and occupational therapy have been working with the enrollee. The enrollee is requiring moderate assistance for tub and toilet transfers. The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours a day/5 days a week, or 15 hours over 7 consecutive days, of therapy 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences (CPT code 74183) to be performed by an out-of-network provider.
You asked the Plan to pre-approve the MRI. You say that you had a seizure in the past from having a standard MRI. The Plan denied your request. The Plan says they agree that your abnormal computed tomography (CT) scan makes an MRI scan medically necessary. The Plan states that such service is available in-network, and there are no extenuating circumstances related to geographic access, compelling continuity of care making it medically necessary that future care come only from this provider, or unique medically-recognized qualifications of the requested out-of-network provider to justify prior authorization of out-of-network benefits.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve MRI, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences (CPT code 74183) to be performed by an out-of-network provider.
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 disagree with the denial. The Plan denied your request. The Plan says the 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on April 19, 2021 with pneumonia, abdominal abscess, and fistula. He is currently undergoing treatment at an acute care hospital (ACH) for complications related to abdominal surgery. 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. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110), and a partial lower denture (D5214).
You asked the Plan to pre-approve a complete upper denture, and a partial lower denture. You say that you thought that you had dental benefits that would cover these services. The Plan denied your request. The Plan says the services requested are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110), and a partial lower denture (D5214).
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 disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the record show that you were admitted to a skilled nursing facility on March 12, 2021 for rehabilitation services. The most recent therapy notes show that you need minimum assistance for walking short distances using a walker. You need minimal assistance with bed mobility and moderate to maximal assistance with transfers. The complexity of your nursing, medical and rehabilitation needs does not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sildenafil.

You asked the Plan to pre-approve Sildenafil. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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 Sildenafil.

Benefits for Sildenafil 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network psychology provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says medically necessary care is available in-network.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network psychology provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the services of a HH/hospice aide in HH or hospice settings.
You asked the Plan to pre-approve the services of a HH/hospice aide. You say that you would like to request home health services to assist the enrollee bathing. The Plan denied your request. The Plan says there are no orders for the enrollee to have skilled services, and there are no skilled services being provided in the home.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We 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 of a HH/hospice aide have not been met. Therefore, we decided that the Plan does not have to pre-approve the services of a HH/hospice aide in HH or hospice settings.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal cord stimulators (63650).
You asked the Plan to pre-approve the spinal cord stimulators. You say that the stimulators are medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that Spinal Cord stimulators are only covered for certain indications. We looked at the file and Medicare rules. The record shows the enrollee has a diagnosis of scoliosis and lumbar spondylosis without radiculopathy. This is not among the covered indications listed in the coverage criteria. Based on this information, we decided that Medicare rules for coverage of the spinal cord stimulators have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal cord stimulators (63650).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.

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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal: endodontic therapy, anterior tooth (D3310)

You asked the Plan to pre-approve a root canal. You say that the service would greatly improve the enrollee's quality of life The Plan denied your request. The Plan says a root canal has already been covered for the enrollee once in the 2021 calendar year and another is not covered under the dental benefit.

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. The Plan covers a root canal once per calendar year.

We looked at the file and Medicare rules. The Plan provided documentation that a root canal was previously covered for the enrollee in March 2021, exhausting their benefit. Based on this information, we decided that the Plan does not have to pre-approve a root canal: endodontic therapy, anterior tooth (D3310)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omeprazole cap 20mg 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 medication falls under Part D coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Omeprazole cap 20mg for
the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702) for the enrollee.

You asked the Plan to pre-approve a MyoPro Motion G Orthotic device (L8702). You say that this device is medically necessary.The Plan denied your request. The Plan says medical necessity has not been established. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a MyoPro Motion G Orthotic device (L8702).The Maximus Physician Reviewer determined that the requested orthotic device was medically reasonable and necessary. The Plan argues that the published, peer-reviewed, scientific literature is not sufficient and therefore this device is investigational for this patient's condition of hemiplegia from a stroke. The prospective clinical studies lack data measuring objective outcomes, improved performance and specific patient selection criteria. Further well-designed randomized, controlled clinical trials with adequate follow-up are needed to determine the overall benefit of these devices. Furthermore, the requested L8702 is not being furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition of hemiplegia from a stroke or to improve the function of a malformed body member from hemiplegia from a stroke.

The medical records show the enrollee is a 57-year-old with left hemiparesis as the result of a stroke in 2013. The case file only contains Progress Notes by the enrollee's geriatric medicine physician from January of 2020. The physician's plan at that time included an ambulatory referral to Physical Medicine Rehab. The note contained no discussion of a myoelectric orthotic device. There is a Telehealth visit from April 29, 2020 that states the device would allow for further extension and motion."The prescription was written on June 6, 2020 and a "Medical/Orthotic History and Physical Exam Review"by the Chief Medical Officer of Myomo, Inc.is dated June 10, 2020. Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support that the MyoPro Motion G Orthotic device was medically reasonable and necessary for the enrollee in this case. The clinical documentation by the ordering physician does not support that the requested orthotic device meets but does not exceed the enrollee's medical need and does not indicate that it is least as beneficial as existing and available medically appropriate alternatives. 

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 MyoPro Motion G Orthotic device (L8702) have not been met.Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702) for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS device.

You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria
have not been met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 a CardioMEMS device. Our reviewer
says that the requested items/services are considered medically reasonable and necessary in this case. Our
physician reviewer found in this case, the enrollee has NYHA class III heart failure and has been hospitalized
in the past year. The elements of the Food and Drug Administration indication are satisfied. The requested
service is recommended.

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 CardioMEMS device have been met. Therefore, we decided that the Plan has
to pre-approve a CardioMEMS device.

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 admission to a LTACH.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the services can be safely received in another setting.

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 you are currently undergoing treatment at an acute care hospital (ACH). You are not
intubated/ventilated. There is no evidence that you require 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. You can then be transferred/discharged to a lower level of care for any ongoing long
term care 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 admission to a LTACH.