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

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that a LTACH admission is medically necessary for the enrollee.The Plandenied your request. The Plan says the LTACH admission is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrolleeis currently undergoing treatment at an acute care hospital (ACH) following coronary bypass surgery. The enrollee'spost-operative course was complicated by cardiogenic shock, a cardiac arrest and renal failure. The enrollee was intubated/ventilated and started on hemodialysis. Hesubsequently received a tracheotomy and appears to have since been weaned off the ventilator to a tracheotomy collar. Given the enrollee's neurologic status, it is unclear if decannulation is expected. 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. The enrollee 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-approvelong term acute care hospital (LTACH) services.
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 IRF care. The Plan denied your request. The Plan says the enrollee does not require care that involves a doctor in the field of rehabilitation medicine. The Plan says that the notes do not show that the enrollee has complex care needs that require a coordinated team approach. The Plan says that the notes do not show that the enrollee must have an intensive therapy program in order to improve self-care functioning and walking. The Plan says that the enrollee's medical & therapy needs can be met in a skilled nursing unit.
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 enrollee is getting medically stable, with debility and functional dependence and there is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation physician three times per week. There is no evidence of a need for acute rehab nursing care. While the enrollee may benefit from continuing physical therapy and occupational therapy, there is no evidence of that the enrollee can tolerate intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The enrollee currently needs maximum assist for most activities and is participating in therapies for 15 minutes at a 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 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-approveintermittent limb compression device.You asked the Plan to pre-approveintermittent limb compression device. You say that the enrollee needs this device.The Plan denied your request. The Plan says the denial of authorizationfor this device is correct, because there is no indication of lymphedema extending into the chest, trunk, or abdomen.The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema xtending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We asked our physician reviewer to carefully review the case file andapply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve intermittent limb compression device. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested pneumatic compression device. Our physician reviewer found there is no evidence provided of any chest, trunk, or abdomen edema which has failed standard treatment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device have not been met.Therefore, we decided that the Plan does not have to pre-approveintermittent limb compression device.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve food thickener (B4100).
You asked the Plan to pre-approve the thickener. You say that you have trouble swallowing because of dysphasia. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the definition of HCPCS code B4100 is "Food thickener, administered orally, per ounce." We find that CPT code B4100 is not supported in the medical record. Reimbursement is not available for the requested code - HCPCS B4100. The Fee Schedule identifies this code with status E1 - which represents a code that is not payable. Based on this information, we decided that Medicare rules for coverage of the thickener have not been met. Therefore, we decided that the Plan does not have to pre-approve food thickener (B4100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental implant (HCPCS A9270).
You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit under the plan.
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 dental implant (HCPCS A9270).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is 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 rulesto determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for failure to thrive following surgery for colon cancer. The enrollee has had a complicated post-operative course complicated by anastomotic leakage/bleeding, psoas hemorrhages, respiratory failure and renal failure. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee is noted to have a poor prognosis. 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. The enrollee 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-approvelong term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond February 18, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee has had multiple surgeries and multiple complications and needs extended rehab services in the SNF. The Plan denied your request. The Plan says the enrollee has used up his 100 day SNF benefit in the benefit period starting on September 25, 2019.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from September 25, 2019 to February 18, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond February 18, 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 the records provided support the need for IRF care. The Plan denied your request. The Plan says the clinical information provided does not support the medical necessity 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 enrollee was medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care. The enrollee may benefit from further physical therapy and an occupational therapist, but does not require an intensive therapy program. An IRF admission is not medically necessary based on medical stability. The clinical information provided did not support the medical necessity for Inpatient Rehab. The enrollee's therapy needs can be met at a lower intensity rehab such as in an skilled nursing facility (SNF) 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD), also known as minimally invasive lumbar decompression (MILD).
You asked the Plan to pre-approve the PILD procedure. You say that you feel that this may have been incorrectly denied as a spinal fusion. You say that this is a clinically proven surgery for which all criteria are met. The Plan denied your request. The Plan says this is only covered when provided to an enrollee who is participating in an approved clinical study.
The Plan must follow Medicare rules. Medicare rules say that PILD is covered under the CED process for enrollees who are participating in an approved clinical study. There is no evidence of participation in a clinical study. If such evidence exists, this should be forwarded to the Plan directly. Therefore, we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD), also known as minimally invasive lumbar decompression (MILD).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee's medical conditions support that the enrollee would benefit from an intensive rehab program.The Plan denied your request. The Plan says the enrollee's medical complexity does not require oversight by a rehab physician, or an interdisciplinary approach to rehab.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 physician reviewer found that the enrollee was noted to have uncontrolled diabetes. He forgets to take medications at times, and has memory issues. 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 is at moderate to minimal assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.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 havenot been met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebone marrow aspiration (20939).You asked the Plan to pre-approvebone marrow aspiration (20939). You say that the requested bone marrow aspiration is medically necessary.The Plan denied your request. The Plan says the requested bone marrow aspiration is not medically necessary.The Plan must followMedicare 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 bone marrow aspiration (20939). Our reviewer says that the requested bone marrow aspiration is not medically necessary. Our physician reviewer found the enrollee is with radicular pain and lumbar spinal stenosis and spondylolysis. The plan approved a lumbar laminectomy and inpatient hospital stay. Bone marrow aspiration remains experimental. More research is needed to show safety and efficacy. It is not the standard of care for spinal fusion. The requested bone marrow aspiration is not medically necessary in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration (20939) have not been met.Therefore, wedecided that the Plan does not have to pre-approvebone marrow aspiration (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments.
You asked the Plan to pre-approve these services. You say that your current wheelchair is falling apart. The Plan denied your request. The Plan says that you do not have a qualifying diagnosis for a Group 3 very heavy duty power wheelchair.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to start Ketamine for the enrollee.
You asked the Plan to pre-approve the consultation. You say that this is medically necessary. The Plan denied your request. The Plan says the safety of Ketamine is unknown.
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 consultation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no quality available evidence to support this treatment for these specific conditions - generalized anxiety disorder and bipolar disorder. A closely related meta-analysis of 10 studies using Ketamine to treat major depressive disorder found no significant difference between ketamine and other induction agents and showed no long-term benefit overall. Without sufficient safety and effectiveness data to support this request in this clinical situation, the requested consultation for ketamine infusion will be considered not 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 the consultation have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation to start Ketamine for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Erbitux 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 claims for routine costs associated with a clinical trial are not payable
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the drug as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Erbitux for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee's current needs can be safely met at a less intensive care setting such as in a custodial level of care.
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 the enrollee's 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referralan outof-
network 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 care is able to be managed by a network provider.
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
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha.
You asked the Plan to pre-approve Repatha. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Repatha is not covered under the enrollee's Medicare Part B benefit.
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 Repatha.
Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.