Persius/hicric huggingface dataset:
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 records provided support the need for care in an IRF. You say that the enrollee is entitled to an aggressive physical therapy program that would get her back to the level of physical ability that she was at prior to the accident. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have 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 above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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. The enrollee was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve headgear for a positive airway pressure (PAP) device.

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 covered.

The Plan must follow Medicare rules. The rules say that headgear is covered once every six months. 

We looked at the file and Medicare rules. The item at issue is headgear for a PAP device. This item is covered by Medicare once every six months. The file shows that you last received headgear on October 23, 2020. 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 headgear for a positive airway pressure (PAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you are allergic to toilet paper. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve ankle-foot orthosis (AFO). You say that you have been requested to provide this item by the prescribing physician. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this provider is out-of-network with the Plan and this item can be obtained from an in-network supplier.

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 the medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).

You asked the Plan to pre-approve a total electric hospital bed. You say that the item is medically necessary. The Plan denied your request. The Plan says fully electric hospital bed are considered a convenience item and are not reasonable and necessary equipment.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
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 enrollee is the main provider in her household and her husband cannot care for himself. You say that the enrollee needs to regain her strength so that she can get back home. You say that the enrollee needs intense rehab. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive services in another setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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. The enrollee was admitted for surgical treatment of a hip fracture after a fall. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve these services. You say that your feet have grown and it is causing discomfort. The Plan denied your request. The Plan says the services are not covered.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stationary exercise bike.

You asked the Plan to pre-approve a stationary exercise bike. You say that the enrollee's physical therapist advised the enrollee should get a stationary bike. The Plan denied your request. The Plan says exercise equipment is not primarily and customarily used to serve a medical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Home exercise/ physical therapy equipment that can be obtained without a prescription is considered to be an over the counter supply, is not considered DME, and is therefore ineligible for coverage. Therefore, we decided that the Plan does not have to pre-approve a stationary exercise bike.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.

You asked the Plan to pre-approve the automatic blood pressure monitor. You say that you would like reconsideration because the member is unable to control their blood pressure even with medication. The Plan denied your request. The Plan says the blood pressure monitor is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. 

The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
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 enrollee is at risk of delayed progress in returning to prior level of functioning, risk of deconditioning, and even risk of death. You say that the enrollee meets all of the necessary guidelines for IRF care. The Plan denied your request. The Plan says the records do not show that the enrollee meets the guidelines for coverage of care in an IRF.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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. The enrollee was admitted for gangrene of right foot and had right below the knee amputation. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 Synvisc injections (J7325).

You asked the Plan to pre-approve the Synvisc injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says six months has not elapsed since the last series of injections.

The Plan must follow Medicare rules. Medicare rules say that for a repeat series of these injections, at least six months must have elapsed since the prior series of injections. 

We looked at the file and Medicare rules. The request is for the injections to be administered after 5 months. Medicare rules require that 6 months elapse before a repeat injection series. Based on this information, we decided that Medicare rules for coverage of the Synvisc injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc injections (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural neurostimulator.

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 neurostimulator trial 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 enrollee has chronic low back pain. Physical exam shows signs of radicular pain and decreased range of motion. He was referred to a surgery but there is no documentation that he obtained an opinion. He has not had prior spine surgery and does not have any other evidence based indication for the SCS trial or Dorsal Root Ganglion stimulator. The services are 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 an epidural neurostimulator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Prolaris Prostate Cancer Genomic Assay.

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 testing is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that Prolaris testing 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 testing is not medically necessary. Our physician reviewer found the submitted records show that you have a diagnosis of prostate cancer with extensive disease in both lobes. Your cancer is in the intermediate risk category with less than 50 percent positive cores. You have a Gleason score of 7 and a prostate specific antigen (PSA) between 10 to 20 ng/m. The criteria for coverage of the requested testing are not met and the services are not reasonable or medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Prolaris Prostate Cancer Genomic Assay.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a service animal.

You asked the Plan to pre-approve a service animal. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says service animals are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Medicare does not cover the cost of service animals. Based on this information, we decided that Medicare rules for coverage of a service animal have not been met. Therefore, we decided that the Plan does not have to pre-approve a service animal.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brow ptosis repair and blepharoplasty.

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 brow ptosis repair and blepharoplasty are 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 enrollee has bilateral brow ptosis and right-sided dermatochalsis with alleged visual impairment from the abnormalities. Visual field testing indicates more than a twelve degree and 30percent impairment of visual fields without taping. Taping improves the left field indicating more than 30 percent loss in the untaped position. No improvement is seen on the right. The documentation does not include evidence of dermatitis or visual difficulties. The physician note provided indicates that the physician discussed that coverage is not provided for cosmetic reasons. The provided documentation does not provide sufficient evidence of improvement in visual fields or evidence of other pathology required by the Medicare rules. 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 brow ptosis repair and blepharoplasty.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amniotic fluid injection of the right hip / Fluid flow x1 2cc units (CPT Code Q4206).

You asked the Plan to pre-approve the services. You say that the enrollee would like to have this injection versus having to have right hip surgery. 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the progress note, notes plan is for surgery. The use of this injection would not be indicated with a plan in place for total hip replacement surgery. Furthermore, large well-designed studies in the peer review scientific literature supporting the use of this injection are lacking. Published studies do not demonstrate any significant long-term health outcome advantage with this request, as an alternative to standard surgical treatment. Large population sufficiently powered randomized controlled trials that demonstrate long-term health outcome advantages are also lacking. Therefore, the request for amniotic fluid injection of the right hip/Fluid flow x1 2cc units is 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve amniotic fluid injection of the right hip / Fluid flow x1 2cc units (CPT Code Q4206).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Home Ventilator, (E0466 X 12 months).

You asked the Plan to pre-approve Home Ventilator. You say that the item is medically necessary. The Plan denied your request. The Plan says the submitted information does not show that this ventilator is being used consistently.

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 Home Ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found the patient does not have neuromuscular disease or thoracic restrictive disease and the usage of the home ventilator does not meet Medicare criteria of at least 4 hours/day for at least 70% of days. The usage is insufficient to provide clinical benefit.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Home Ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve Home Ventilator, (E0466 X 12 months).