Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not require daily skilled therapy services on an inpatient basis.
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 SNF services. Our physician reviewer found that you are at an independent assist level for rolling, sitting and standing up, supervision for toilet transfers and bathing, and setup for eating and dressing. You do not have documented skilled nursing or skilled therapy service needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. 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 continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CTA, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing (CPT code 74174), for the enrollee.
You asked the Plan to pre-approve the CTA. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says they need notes that say why the enrollee's doctor wants this test. The Plan states a different test, abdominal CTA, might be better for the enrollee's problem. The Plan states the information they got did not show these things have been done.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the CTA. Our physician reviewer found the review has determined that the do not medical records provided meet the requirements listed in the LCD for Medicare coverage. 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 CTA have not been met. Therefore, we decided that the Plan does not have to pre-approve CTA, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing (CPT code 74174), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services from August 24, 2021 forward.
You asked the Plan to pre-approve inpatient psychiatric services from August 24, 2021 forward. You say that the enrollee still has mood instability, anxiety and depression. The Plan denied your request. The Plan says continued inpatient psychiatric services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient psychiatric services from August 24, 2021 forward. Our reviewer says that the health plan's denial of continued inpatient psychiatric services is appropriate. Our physician reviewer found the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment/detoxification as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. This patient was not showing any withdrawal symptoms requiring this 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 inpatient psychiatric services from August 24, 2021 forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services from August 24, 2021 forward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Perjeta and Herceptin chemotherapy and administration provided on April 6, 2021.
You asked the Plan to pay for chemotherapy administration (96413, 96417), injection, trastuzumab, excludes biosimilar, 10 mg (J9355), and injection, pertuzumab, 1 mg (J9306). You say that the chemotherapy was medically necessary. The Plan denied your request. The Plan says the combination of trastuzumab and pertuzumab for the treatment of metastatic pancreatic cancer is not FDA approved or supported by major compendia.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for chemotherapy administration (96413, 96417), injection, trastuzumab, excludes biosimilar, 10 mg (J9355), and injection, pertuzumab, 1 mg (J9306). Our reviewer says that the drugs were not medically reasonable and necessary. Our physician reviewer found the use of Perjeta and Herceptin is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. There is clinical evidence in gastric cancer but in combination with cytotoxic chemotherapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chemotherapy administration (96413, 96417), injection, trastuzumab, excludes biosimilar, 10 mg (J9355), and injection, pertuzumab, 1 mg (J9306), have not been met. Therefore, we decided that the Plan does not have to pay for Perjeta and Herceptin chemotherapy and administration provided on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve teeth extractions (CPT code 99212).

You asked the Plan to pre-approve teeth extractions. You say that the extractions need to be done because it is affecting your blood sugar. The Plan denied your request. The Plan says removal of teeth is not being covered by Medicare.

Medicare generally does not cover dental services. The Plan follows the same rule. Teeth extractions are not covered by the Health Plan or Medicare. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve teeth extractions (CPT code 99212).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that you do not require daily in-patient skilled therapy.
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 SNF services. Our physician reviewer found that you are at a standby assist level for standing up and sitting down, and a contact guard assist for walking using a rolling walker. You do not have documented skilled nursing needs. However, you do have documented skilled therapy needs. Given your traumatic brain injury, a brief period of skilled services is reasonable to establish a maintenance program to prevent deterioration of your condition. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve a skilled nursing facility (SNF) admission and services.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the requested home ventilator has a higher respiratory flow capability than a traditional home bilevel positive airway pressure (BiPAP) or BiPAP with average volume-assured pressure support (AVAPS). You say that a home ventilator is indicated and BiPAP would be insufficient for your long-term treatment. The Plan denied your request. The Plan says the ventilator is being requested to help the enrollee's breathing at various times of the night and day because of lung disease. The Plan say that Medicare does not cover ventilators used in this way.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 portable ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically necessary for this enrollee.
The diagnoses are obstructive sleep apnea, obesity hypoventilation syndrome, and heart failure with preserved ejection fraction. These are not covered diagnoses. There is no diagnosis of chronic obstructive pulmonary disease, neuromuscular disease, or thoracic restrictive disease. The enrollee does have CO2 retention, which improved in the hospital using bilevel positive airway pressure (BiPAP). Complete correction of the CO2 over a short period of time is not a reasonable expectation and does not represent BiPAP failure. BiPAP or CPAP are the appropriate treatments for this enrollee. Medicare does not cover a home ventilator when use as BiPAP, and the average volume-assured pressure support (AVAPS) mode of support can be provided via BiPAP. 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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).

You asked the Plan to pre-approve the surgery. You say that you were diagnosed with spinal stenosis a little over three (3) years ago. You state you had an epidural to block the nerve pain. The Plan denied your request. The Plan says the services are considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron 08mg Tablet, for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says this medication falls under Part D coverage, but the enrollee has no Part D pharmacy benefit. The Plan states this medication does not fall under Part B. The Plan states the enrollee has no commercial pharmacy benefit administered by the Health Plan.
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 Ondansetron 08mg Tablet, for the enrollee.
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide CPAP supplies.
You asked the Plan to provide CPAP supplies represented by codes A7034, A7035, A7038, and A7039. You say that you need replacement parts and do not have the funds to pay for a new CPAP. The Plan denied your request. The Plan says all DME items require detailed written orders from a physician prior to billing.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order or relevant medical records which support medical necessity for the supplies provided in this case. There is no physician order as required. The record shows that
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to provide CPAP supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.
You asked the Plan to pre-approve an inpatient hospital admission. You say that , due to the enrollee's age and medical conditions, an inpatient hospital admission is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that, should medical issues develop, they will review up on request.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 an inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for an inpatient hospital admission are
met in this case. Our physician reviewer found the enrollee is having routine knee arthroplasty. There is no need for inpatient admission. The surgery may be safely performed with an observational stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high strength, lightweight wheelchair (CPT code K0004), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the Medicare rules have not 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 the DME. Our physician reviewer found based on the medical records provided there is no documentation that meets all of the requirements listed in the Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788) for Medicare coverage for the high strength, lightweight manual wheelchair. The provided records do not document all of the following: The enrollee has a mobility limitation that significantly impairs his ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The enrollee's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. The enrollee's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided. Use of a manual wheelchair will significantly improve the enrollee's ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home. The enrollee has not expressed an unwillingness to use the manual wheelchair that is provided in the home. The enrollee has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day or the enrollee has a caregiver who is available, willing, and able to provide assistance with the wheelchair. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve high strength, lightweight wheelchair (CPT code K0004), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve other procedures on the Musculoskeletal System (CPT code 20985), for the enrollee.

You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says the use of computer-assisted navigation is considered investigational for all musculoskeletal orthopedic surgical procedures of the appendicular skeleton. The Plan states Medicare does not cover investigational treatments.

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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no medical need for computer assisted total knee surgery. The procedure may be safely performed without the use of computer assist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet block injection services.

You asked the Plan to pre-approve the facet blocks. You say that you are unable to ambulate throughout your home, due to pain. You say that you cannot complete daily activities. The Plan denied your request. The Plan says the requested shots are not medically necessary because the notes provided do not show that the enrollee has significant back pain with functional limitations, that has not responded to conservative treatments.

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 facet blocks. Our reviewer says that facet blocks are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has an extruded disc, multiple disc bulges and foraminal and central canal stenosis which are clearly documented but not addressed. There is no physical exam documentation that supports the diagnosis of facet joint dysfunction.

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 facet blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve facet block injection services.