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

We decided that the Plan does not have to pre-approve inpatient mental health care.

You asked the Plan to pre-approve inpatient mental health care. You say that this care is medically necessary. The Plan denied your request. The Plan says the criteria for inpatient mental health care have not been met and that outpatient care would be more appropriate.

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 mental health care. Our
reviewer says that the requested inpatient mental health care is not medically necessary. Our physician reviewer found that the enrollee is a 35 year-old male who was admitted to the acute inpatient psychiatric/detoxification hospitalization on July 19, 2021. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. Based upon review the records provided, for the admission of this patient does not meet the criteria for acute inpatient mental health/detoxification group treatment as this patient was not shown to be a danger to himself or others but was without agitation or aggression without perceptual disturbance including auditory, visual hallucinations or delusions. 

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 mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the Vertiflex device. The Plan denied your request. The Plan says this is not medically necessary.
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 Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Superion Interspinous Spacer is indicated for those patients with impaired physical function who experience relief in flexion from symptoms of leg/buttock/groin pain, with or without back pain, who have undergone at least 6 months of non-operative treatment. In this case, the enrollee has chronic low back pain and spinal stenosis. The record indicates that imaging has demonstrated severe spinal stenosis at L3-L4, the level requested for treatment. The elements of the coverage criteria are not satisfied.
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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for arthrocentesis (20610) and a triamcinolone acetonide injection (J3301) provided on March 3, 2021, an office visit provided on March 29, 2021, and a magnetic resonance imaging (MRI) (73721) provided on April 5, 2021.
You asked the Plan to waive the cost-sharing for arthrocentesis, a triamcinolone acetonide injection, an office visit, and an MRI. You say that payment for these services should be included in the payment for surgery you had in December. The Plan denied your request. The Plan says these services processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B drugs, a $40 copayment for services provided in a specialist physician's office, and a $200 copayment for each MRI. You have been asked to pay $40 for arthrocentesis, which was provided in a specialist's office, $1.15 (20% of the $5.76 allowed amount) for a triamcinolone acetonide injection, $40 for an office visit with a specialist, and$200 an MRI. These services are not included in the global package of the surgery you had in December. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-sharing for arthrocentesis (20610) and a triamcinolone acetonide injection (J3301) provided on March 3, 2021, an office visit provided on March 29, 2021, and a magnetic resonance imaging (MRI) (73721) provided on April 5, 2021.
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 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. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for vascular surgery of the leg and developed compartment syndrome. She is now medically stable with no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. She
does require physical and occupational therapy but there is no documented 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 a home ventilator (E0466).
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs this item. The Plan denied your request. The Plan says this is not medically necessary.
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. Our physician reviewer found the records show that the enrollee has chronic hypoxic and hypercarbic respiratory failure, likely due to a combination of chronic obstructive pulmonary disease (COPD) and narcotic-induced hypoventilation. The patient may benefit from nocturnal bilevel positive airway pressure (BiPAP) therapy, but Medicare does not cover a home ventilator when used as 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darzalex Faspro and Velcare for the enrollee.
You asked the Plan to pre-approve Darzalex Faspro and Velcare. You say that these drugs are medically necessary for the enrollee. The Plan denied your request. The Plan says that the requested regimen is only supported for patients that are stem cell transplant eligible.
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 pre-approve Darzalex Faspro and Velcare. Our reviewer says that Darzalex Faspro and Velcare are not medically reasonable and necessary for the enrollee in this case. Darzalex Faspro and Velcade are not FDA-approved for the enrollee's diagnosis. The use of Darzalex Faspro and Velcare in this combination and for 1st line treatment are not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Darzalex Faspro and Velcare.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Darzalex Faspro and Velcare have not been met. Therefore, we decided that the Plan does not have to pre-approve Darzalex Faspro and Velcare for the enrollee.
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 IRF care is medically necessary for this enrollee. The
Plan denied your request. The Plan says criteria for admission to an IRF have not been met. The enrollee's
ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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 that 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 require physical and occupational therapy, but there is no documented need for an intensive
rehabilitation program. 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. Medically necessary
services can be provided in a different 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for total knee replacement and was transferred to a skilled nursing facility on July 27, 2021. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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 patient 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair, for the enrollee.
You asked the Plan to pre-approve the power wheelchair. You say that the wheelchair is necessary. The Plan
denied your request. The Plan says there is insufficient clinical information to reference a specific policy to
make a determination.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Information required to make a determination includes submission of all clinical documentation relating to the
enrollee's diagnosis and the requested procedure. This also includes listing diagnosis and procedure codes.
After review of the information submitted, information does not show sufficient clinical information to
reference a specific policy to make a determination. Specifically, we need CPT/procedure codes. Therefore, the
requested power wheelchair has been denied. Based on this information, we decided that Medicare rules for
coverage of the power wheelchair have not been met. Therefore, we decided that the Plan does not have to preapprove
the power wheelchair, for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been me.

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 there is no documentation provided necessitating admission to an LTACH. 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. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nerve destruction surgery services provided March 4, 2021.

You asked the Plan to waive the copayment for the nerve destruction surgery services. You say that you have never had a copayment for this surgery in the past. The Plan denied your request. The Plan says the copayment has processed correctly in this case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for surgery performed in an outpatient hospital setting. 

You have been asked to pay a $300 copayment for the nerve destruction surgery services. These services fall within the surgery performed in an outpatient hospital setting benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the nerve destruction surgery services provided March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast reconstruction surgery.
You asked the Plan to pre-approve breast reconstruction surgery. You say that this request is medically necessary and is not for cosmetic reasons. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that breast reconstruction is subject to the criteria listed in the Medicare rules section whether placed for reconstructive or cosmetic purposes. 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 breast reconstruction surgery. Our reviewer says that the requested surgery is not medically reasonable and necessary. Our physician reviewer found that you are a 77-year-old woman for whom revision of breast reconstruction is requested. In this case, the record indicates that you have had mastectomies with reconstruction. You feel that the implants are leaking. Physical examination does not demonstrate abnormalities. Imaging demonstrates intact implants. The provided records do not indicate that you have a condition enumerated in the coverage criteria. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of breast reconstruction surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve breast reconstruction surgery.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional physical therapy (PT) visits.

You asked the Plan to pre-approve eight (8) additional PT visits. You say that you had a stem cell transplant
and lost half of your body weight prior to your illness, which is causing you to be weak and you are trying to
regain your strength and balance. You say that the exercises you do at home are not as good as being able to
use the equipment at the facility. The Plan denied your request. The Plan says the additional PT is not
medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 eight (8) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program and you can work on endurance with a home program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eight (8) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits.