Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 home health physical therapy visits.
You asked the Plan to pre-approve the 6 home health physical therapy visits. You say that the records provided support the need for the requested home health visits. The Plan denied your request. The Plan says the enrollee received physical therapy, met the goals, and was discharged. The Plan says that the enrollee does not meet the criteria for home health services.
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 6 home health physical therapy visits. Our reviewer says that the criteria for coverage have not been met.
Our physician reviewer found the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. Our physician reviewer found that the home health agency reported that the enrollee was discharged from their care on September 23, 2020, as all of her therapy goals were met and her maximum potential was reached. The enrollee was reported to be independent with regard to her current status at the time of discharge on September 23, 2020, according to physical therapy notes. 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 6 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sabina sit-to-stand system. 
 
You asked the Plan to pre-approve these services. You say that you need the system to be discharged home. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a patient lift is covered when specific criteria are 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
have muscle weakness due to pneumonia from COVID-19. The records do not show that you are unable to 
transfer from a bed to a chair, wheelchair, or commode without the use of a patient lift. The records do not 
contain a physical examination of your function or a neuromuscular exam to show that the device is required. 
The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Sabina sit-to-stand system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with multiple 
power options. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 2 PWC is covered when specific criteria 
are 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 these services. Our reviewer says that 
the enrollee does not meet the criteria for coverage. Our physician reviewer found the records show that the 
enrollee has a mobility deficit but that it does not significantly impair participation in mobility-related activities 
of daily living (MRADLs) in the home. The July 2, 2020 physician note states that she is independent for 
toileting, bathing, and dressing. The wheelchair accessory of power tilt and recline is not medically necessary 
as the documentation does not reveal use of independent bladder management catheterization, spasticity, 
inability to transfer independently from wheelchair to bed. There is also no significant lower extremity edema 
or evidence of knee bracing or a cast that require power elevating leg rests. The Group 2 power wheelchair and 
accessories exceeds the enrollee's medical 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 2 power wheelchair (PWC) with multiple power options.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home aide services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you do
not have a skilled need that requires the expertise of a licensed professional.
The Plan must follow Medicare rules. The rules say that custodial care is not covered.
The documentation shows that services to assist with preparing food, dressing, light housekeeping, laundry,
cooking, cleaning, and running errands were requested. We looked at the file, and Medicare rules. Custodial
care is not a covered benefit. Based on this information, we decided that Medicare rules for coverage have not
been met. Therefore, we decided that the Plan does not have to pre-approve home aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push-rim power assist system for a manual 
wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you have progressive loss of strength and 
mobility. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a a push-rim power assist system is covered 
when specific criteria are 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 these services. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you 
have had multiple back and neck surgeries. You are approved for an ultralight wheelchair but denied a push-
rim power assist system. You have not been self-propelling a manual wheelchair for at least one year; 
therefore, the services are not medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a push-rim power assist system for a manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650).
You asked the Plan to pre-approve a spinal cord stimulator. 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 follows Medicare rules. Medicare rules say that dorsal column stimulators are covered under certain
circumstances.
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 spinal cord stimulator. Our reviewer
says that the services are not medically necessary. Our physician reviewer found the documentation does not
support that the enrollee has a diagnosis of lumbosacral arachnoiditis, post-surgical or post-traumatic nerve root
injuries, complex regional pain syndrome I & II, phantom limb syndrome, post-herpetic neuralgia, plexopathy,
intercostal neuralgia, cauda equina injury, or incomplete spinal cord injury.
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a spinal cord stimulator (63650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick catheter system. 
 
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 services are noncovered. 
 
The Plan must follow Medicare rules. Medicare rules say that single-use urinary bags are not necessary. 
 
We looked at the file and Medicare rules. The services at issue are a single-use urinary catheter system. These 
services are denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have 
to pre-approve a Purewick catheter system.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay was 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services 
with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. You do not have complex wound 
care or other ongoing SNF level SN need. Your functional level does not require skilled therapy services with 
the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide 
medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy 
services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not 
require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea continuous glucose monitor (CGM).You asked the Planto pre-approvethe CGM. You say that the enrollee is supposed to be testing four or more times per day and have up to four insulin injections per day, which is only not being done due to the high cost of insulin.The Plandenied your request. The Plansayscriteria not met.The Plan follows Medicare rules. Medicare rules say that CGMs are covered only when the above criteria are 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 the CGM. Our reviewer says that the requested CGM is not medically necessary based on LCD criteria. Our physician reviewer found review of submitted records does not support the enrollee is testing blood glucose 4 or more times a day, nor does it support multiple insulin injections each day. Without the support of the documentation, medical necessity cannot be determined.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 CGM have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power scooter repairs. 
 
You asked the Plan to pre-approve these services. You say that your power scooter is broken and needs repairs. 
The Plan denied your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 
 
We looked at the file and Medicare rules. The file shows that the Plan provided a wheelchair that can safely 
and appropriately manage your needs; therefore, the power scooter repairs are not needed. 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 power scooter repairs.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla. 
 
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 self-administered drugs are not covered. 
 
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 Otezla.  
 
Benefits for these services 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCologuard testing (81528).You asked the Plan to pre-approveCologuard testing. 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. Medicare rules say that the CologuardTM test is covered once every three years for Medicare beneficiaries that meet specific criteria.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cologuard testing have not been met. Specifically, the age limit for testing with Cologuard is 50-85 years old. The enrollee is not within the age range allowed.Therefore, we decided that the Plan does not have to pre-approveCologuard testing (81528)
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 can safely receive the services needed in other settings. 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. 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 medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the patient's functional status requires or can tolerate an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's care could be provided in an alternate setting 
such as a skilled nursing facility. 
 
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. The 
member's medical conditions are not sufficiently complex or severe to require LTACH level of care. The 
required care can be provided at a lower level of care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your needs can be met a home with supervision, home health services 
or long term care services. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950), retainer crowns (D6750) and 
pontics (D6240). 
 
You asked the Plan to pre-approve the core buildup, retainer crowns, and pontics. You say that you are not able 
to eat well and are have digestion problems. The Plan denied your request. The Plan says the services in dispute 
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 core 
buildup (D2950), retainer crowns (D6750) and pontics (D6240).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services 
with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. You do not have complex wound 
care or other ongoing SNF level SN need. Your functional level does not require skilled therapy services with 
the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide 
medically necessary and reasonable treatment only in a SNF. You do not require skilled nursing or skilled 
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do 
not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.