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 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. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this 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: 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 you can't care for yourself on your own and are at risk. The Plan denied your request. The Plan says that you can continue to receive appropriate intensive rehabilitation services at the IRF.

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 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: 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 medical needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that this ventilator is medically necessary. The Plan denied your request. The Plan says the criteria for a home ventilator have not been met.
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 home ventilator. Our reviewer says that the requested home ventilator is not medically necessary and reasonable. Our physician reviewer found the patient has severe COPD with chronic hypoxic and hypercarbic respiratory failure and would likely benefit from positive airway pressure (PAP) support at night. However, the average volume-assured pressure support (AVAPS) mode of support that has been ordered for the ventilator can be provided via bilevel positive airway pressure (BiPAP), at much less cost. Medicare does not cover a ventilator when used as BiPAP.
Further, the patient's usage of the ventilator has not met minimum criteria for effectiveness, which are at least 4 hrs/day for at least 70% of days. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752), Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure) (C9753), and Unlisted procedure, spine (22899). You say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says there are not enough studies to show the intracept procedure is safe and effective to treat back pain.
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 destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752), Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure) (C9753), and Unlisted procedure, spine (22899). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental/ investigational. Therefore, the request is deemed 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 destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752), Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure) (C9753), and Unlisted procedure, spine (22899) have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the therapeutic continuous glucose monitor and supplies provided October 5, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor and supplies. You say that you would like this claim reprocessed and approved for payment based on medical necessity. The Plan denied your request. The Plan says that the services are not documented in the patient's medical records.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and necessary for enrollees with diabetes who meet criteria referenced 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 pay for the therapeutic continuous glucose monitor and supplies. Our reviewer says that the requested items were medically reasonable and necessary. Our physician reviewer found that the enrollee is a 67-year-old man with diabetes mellitus who takes Humalog with meals and Lantus 20 units daily. Although the note says to take 5 units Humalog daily, the patient invariably will adjust the dose some depending on the blood glucose level. As this patient's A1C is 5.6%, there is a high chance that he has low blood glucose and the therapeutic continuous glucose monitor would help with this as it enables him to adjust his doses at meals accordingly. 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 therapeutic continuous glucose monitor and supplies have been met. Therefore, we decided that the Plan has to pay for the therapeutic continuous glucose monitor and supplies provided October 5, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health treatment.

You asked the Plan to pre-approve continued inpatient mental health treatment. 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. 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 continued inpatient mental health treatment. Our reviewer says that the services are not medically necessary.

Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of May 27, 2021 forward and could have been treated in a lesser restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression. He was being cooperative and compliant while not showing any acute threats to safety as he awaited placement. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient mental health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health treatment.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar laminectomy decompression surgery.
You asked the Plan to pre-approve lumbar laminectomy decompression surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not met.
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 lumbar laminectomy decompression surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the imaging magnetic resonance imaging (MRI) study does not show severe stenosis or root compression. Criteria for lumbar laminectomy decompression surgery not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar laminectomy decompression surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar laminectomy decompression surgery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 86-year-old female with altered mental status, falls with toe fractures and chronic pain. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. Finally, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for gene analysis of prostate tumor tissue, profiling by real-time PCR of 3 genes (CPT code 81551) provided to the enrollee on January 21, 2021.

You asked the Plan to pay for the laboratory testing. You say that the service should be covered based on Medicare guidelines. 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 pay for the laboratory testing. Our physician reviewer found Medicare guidelines require previous negative biopsy done in last 24 months and persistent risk factors for ConfirmMDx to be approved. CMS guidelines also require a benign prostate biopsy, ConfirmMDx is not approved if the biopsy reveals cancer and this enrollee's biopsy revealed cellular atypia. The review has determined that the medical records provided did not 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 laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for gene analysis of prostate tumor tissue, profiling by real-time PCR of 3 genes (CPT code 81551) provided to the enrollee on January 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical connection and transit tie down kit.

You asked the Plan to pre-approve electrical connection and transit tie down. You say that these are medically necessary for you. The Plan denied your request. The Plan says the denial of authorization for these components is correct, because there is no medical need for the electrical connection and a transit tie down kit is primarily for use outside of the home.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

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 electrical connection and transit tie down. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records show that you are independent with bathing, dressing, feeding, and grooming indicating that your upper extremity strength and function are adequate to control the power wheelchair functions with their own switches, so control through a joystick is not 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 electrical connection have not been met. Furthermore, a transit tie down kit is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve an electrical connection and transit tie down kit.
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 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. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. You do require physical and occupational therapy but there is no documented
need for an intensive rehabilitation program.

Medically necessary services can be provided in a different level of care. There is not a reasonable expectation
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve at the in-network rate the incision or partial removal of foot bone (other than big toe) to straighten toe (28308) with an out-of-network (OON) provider.
You asked the Plan to pre-approve at the in-network rate the incision or partial removal of foot bone (other than big toe) to straighten toe. You say that this request is medically necessary. The Plan denied your request. The Plan says that they have providers in-network available to provide the services you need.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. We looked at the file, and Medicare rules. The file indicates that you were previously approved for a consultation with an OON provider based on not having providers in-network available to treat your specific medical needs. Therefore, it is reasonable to assume that the Plan's network providers would not be willing to provide this surgery and an OON provider is the only provider available to meet your needs. Because the Plan cannot provide for this service in-network, it is reasonable for you to be charged an in-network rate for this service. Based on this information, we decided that Medicare rules for coverage of the incision or partial removal of foot bone (other than big toe) to straighten toe have been met. Therefore, we decided that the Plan has to pre-approve at the in-network rate the incision or partial removal of foot bone (other than big toe) to straighten toe (28308) with an out-of-network (OON) provider.
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.