Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan hasto pre-approveIMRT radiation therapy.You asked the Plan to pre-approveIMRT radiation therapy. You say that the requested IMRT radiation therapy is medically necessary.The Plan denied your request. The Plan says that the requested IMRT radiation therapy is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IMRT radiation therapy. Our reviewer says that the requested IMRT radiation therapy ismedically necessary. Our physician reviewer found IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. IMRT generally implies inverse planning algorithms, i.e. the physician determines radiation treatment parameters to maximize dose to the target and minimize dose to normal tissues, and the planning algorithm maximizes the adherence to these parameters by modifying the beam spatially and/or temporally.Based on the documentation provided for review, IMRT is medically necessary when other forms of external beam radiation cannot be as effective either with respect to efficacy or toxicity. With skin cancers, there are innumerable ways to treat radiation -the AIM review mentions HDR brachytherapy or a Leipzig applicator -though not all practices have access to these technologies. With respect to external beam radiation, orthovoltage radiation (low energy) or electron beam radiation are standard approaches, though this enrollee would be unable to travel to the nearest orthovoltage machine (and it is not clear if this is within the enrollee's insurance network). With multifocal lesions across complex surfaces, as is the case with this enrollee, electron therapy would not likely provide a homogeneous dose delivery. That leaves 3D radiation or IMRT-and 3D radiation is also unlikely to be able to safely and effectively deliver radiation across a complex surface. This enrollee's treatment can be considered a head and neck radiation therapy treatment for which IMRT can be considered standard. The radiation target in the treatment of multiple skin cancers of the face/head is a complex shaped volume for which IMRT is well-suited. IMRT is expected to improve the dose coverage and dose homogeneity. Not using IMRT (in favor of 3D radiation or electron therapy) for this enrollee would be substandard care, and IMRT is well within the accepted standard of medical practice.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMRT radiation therapy have been met.Therefore, we decided that the Plan has to pre-approveIMRT radiation therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan for the enrollee.
You asked the Plan to pre-approve the drug. You say that the drug is a standard of care, and is not a clinical trial. The Plan denied your request. The Plan says the enrollee is in a clinical trial.
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 Rituxan for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara injection for the enrollee.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee does not have Part D coverage.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 Stelara injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on September 4, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the submitted medical records reflect a conflicting date other than the billed date of service.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthedrug testing services provided to the enrollee on September 4, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided.You asked the Plan to pre-approve the physician's services. You say that this physician was previously your pain management specialist who successfully managed your chronic pain for ten years. The Plan denied your request. The Plan says the services are available within the Plan's network of providers.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided.
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 services are medically necessary.The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physicianreviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for osteomyelitis of the foot/heel. The enrollee is receiving wound care and a prolonged course of antibiotics. The enrollee is not intubated/ventilated. 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.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 for enrollee.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 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 services are not medically necessary. Our physician reviewer found the enrollee underwent nailing of a femur fracture on February 22, 2020. She was noted at admission to have a urinary tract infection. On February 23, 2020 she needed modified to maximal assist for bathing, toileting, and dressing. She could stand with a rolling walker with assistance but was unable to take any steps. The complexity of her nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an intensive therapy program 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 for enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (POV) for the enrollee.You asked the Plan to pre-approve a POV. You say that  The Plan denied your request. The Plan says that there is no in-home need.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the enrollee's condition can be improved by a walker, cane or manual wheelchair and that the request is for use outside the home. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (POV) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 16, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.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 indenying the request to pre-approve admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee admitted to the hospital on 2/22/20 and started on Clindamycin forleft foot cellulitis. Her C -reactive protein (CRP) level is improving, fever is resolving. Per a 2/27/20 progress note the enrollee has right forefoot cellulitis with superficial abscess concern for deep abscess/septic arthritis first metatarsophalangeal joint. There is plan for foot washout. On 2/27/20 it was noted that MRI was negative for osteomyelitis. Hypertension has been poorly controlled despite Hydralazine. Blood sugars have been fluctuating. She is on Prednisone for temporal arteritis with tapering schedule. The enrollee's current level of function is independent with bed mobility and supervised with transfers and ambulates 120 feet with rolling walker and supervision. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee appears to have continued acute care medical needs such as uncontrolled/labile blood sugars, uncontrolled blood pressure with recent medication adjustments and a 2/27/20 document that states the enrollee needs a foot washout. The medical issues should be stabilized prior to transfer to a rehabilitation facility or hospital discharge. Furthermore, this enrollee's high functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in aSNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on 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 admission to a skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Morphine Sul Sol 100/5ml.You asked the Planto pre-approve the drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested medication is denied as a benefit exclusion.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 Plandoes not haveto pre-approveMorphine Sul Sol 100/5ml.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an UpWalker.
You asked the Plan to pre-approve the UpWalker. You say that you need the UpWalker because it prevents you
from arching over and falling forward. The Plan denied your request. The Plan says the UpWalker is not
covered in accord with Medicare guidelines.
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 UpWalker. Our reviewer says that
the request for the UpWalker is not medically necessary per Social Security Act, Section 1862(a)(1)(A). Our
physician reviewer found the rules say that medically necessary services are those that are reasonable and
necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed
body member. The documentation reveals improved posture and gait in therapy with the walker the enrollee
currently uses. There is no evidence that the UpWalker will improve a malformed body member or is medically
necessary for the diagnosis and treatment of the enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the UpWalker have not been met. Therefore, we decided that the Plan does not
have to pre-approve an UpWalker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962) for the enrollee.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that there is no documentation that supports that the member's activity subjects him to harsh environmental situations or that he engages in any extraordinary activities that would justify the need for extra protection with a flexible outer surface covering system.
The Plan must follow Medicare rules. Medicare rules say that the protective outer surface covering system is used by a beneficiary who has special needs for protection against unusually harsh environmental situations. We looked at the file and Medicare rules. The record does not show the enrollee is subject to harsh environmental situation. 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 addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora chiropractic office visit (99201) provided on November 5, 2019.You asked the Plan to pay fora chiropractic office visit. You say that this should be covered.The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay fora chiropractic office visit (99201) provided on November 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received 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 enrollee's medical conditions appear stable. There are no wound care needs. There are no unaddressed medical issues. She does not require medical oversight of her condition at an acute hospital level of care. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at an SNF level. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 the SNF services. You say that SNF care is needed because you are not back to your baseline. You say that you live alone and have stairs you need to be able to maneuver before returning home. You say that you need to be monitored by skilled personnel because of your low blood pressure. The Plan denied your request. The Plan says the enrollee's needs can be safely provided at a lower level of care. The Plan says that the enrollee does not need daily skilled therapy or daily skilled nursing 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services. Our physician reviewer found that the enrollee does require skilled therapy services, but not on a daily basis. The enrollee does not require the necessary services on 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 the 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the
enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says Medicare will not pay for skilled nursing services after the effective date of 2/9/20.
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 the services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled
nursing or therapy services on a daily basis. The enrollee 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.