Persius/hicric huggingface dataset:
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 gangrene and a a right below the knee amputation. Medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Albuterol nebulizer solution.

You asked the Plan to pre-approve a tier exception. You say that this is medically necessary for you. The Plan denied your request. The Plan says that Part B covered products are not eligible for reduction to a lower co-payment.

The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. 

The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Albuterol nebulizer solution.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis, open, SI joint, including obtaining bone graft, including instrumentation, when performed (CPT code 27280), for the enrollee.

You asked the Plan to pre-approve the services. You say that the procedure is deemed medically necessary. 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 pre-approve the services. Our physician reviewer found the enrollee presented with lumbar pain that radiates to the bilateral buttock, hip, thigh, knee, lower leg, and foot including all the toes and, also radiates to the flanks bilaterally. The back pain is constricting, deep, disabling, exhausting, horrible, nagging, numb, pressure, sharp, shooting, stabbing and uncomfortable. The back pain at its worst is 10/10 and at best 8/10. The pain is made better by chiropractic care, heat, ice, brace and made worse by activity, bending, climbing stairs, coughing, exercise, lifting, sneezing, stress, walking and weather changes. Exam reveals decreased range of motion. There is tenderness to palpation. Lower back pain is exacerbated in flexion. Spasm is noted. Lumbar facet testing is positive bilaterally. Hypermobility noted at the offending segment. There is weakness in the tibialis anterior, extensor hallucis longus, and gastrocnemius, peroneals on the right; with mild weakness noted on the left. There is an antalgic giant noted with a limp, stooped gait, unsteady gait/slow. Sensory is decreased in the lateral and plantar foot and lateral leg and dorsal foot bilaterally. Deep tendon reflexes are decreased at the bilateral patellar and Achilles.

However, multiple other plausible pain generators (including at the lumbosacral spine) are evident. The clinical findings do not support SI pathology. Imaging studies do not corroborate SI joint pathology. A trial of SI joint injections has not been documented. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. LCD indications have not been met. Therefore, the request for arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation is not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis, open, SI joint, including obtaining bone graft, including instrumentation, when performed (CPT code 27280), for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pharmacogenomic panel.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this service was not reported correctly.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.

The enrollee was referred for the laboratory services by a contract provider. The file does not show that the plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the laboratory services is considered approved by the plan. Additionally, the record indicates that the ordering physician requested this testing to better inform the member's treatment. Therefore, we decided that the Plan has to pay for the pharmacogenomic panel.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not have a diagnosis of symptoms that would warrant evaluation with this scan.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found there is no documentation of red flag findings in the provided records to support CT imaging in preference to a repeat ultrasound. The chart from 2/8/21 included this entry: "abdomen is soft without focal masses or tenderness." The available records do not support suspected ischemia, bloody stool, prior gastric bypass, or that you are immunocompromised.

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve combination sit-to-stand frame/table system, any size
including pediatric, with seat lift feature, with or without wheels (CPT code E0637), for the enrollee.

You asked the Plan to pre-approve the sit to stand frame/table system. You say that you are requesting review
of denial of services. The Plan denied your request. The Plan says this request is considered not medically
necessary because a stand assist lift device is considered a deluxe item that would serve as a comfort and
convenience item.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve combination sit-to-stand frame/table system, any size
including pediatric, with seat lift feature, with or without wheels (CPT code E0637), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a porcelain/ceramic crown (D2740) for tooth #30.

You asked the Plan to pre-approve the crown. You say that your tooth is broken, and two separate dental providers have told you that this service is necessary. The Plan denied your request. The Plan says that this service is not necessary. Per their review, the tooth does not appear to have significant breakdown due to decay or trauma.

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. The Plan covers the crown when the services are medically necessary and reasonable.

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 crown. Our reviewer says that the criteria for coverage for a crown (D2740) for the requested tooth has been met. Our physician reviewer found the enrollee's dental record and radiograph indicates that the tooth in question has a large restoration with a cuspal fracture. It is the opinion of our medical reviewer that this service is necessary to provide optimal masticatory function.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-approve a porcelain/ceramic crown (D2740) for tooth #30.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the walk-in tub (K1003).

You asked the Plan to pre-approve the walk-in tub. You say that you would like reconsideration because you are concerned about slipping getting in and out of your bathtub. The Plan denied your request. The Plan says this equipment is not primarily medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 

This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the walk-in tub (K1003).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services.

You asked the Plan to pre-approve personal care services. You say that the enrollee needs help with personal care, such as bathing, dressing, and fixing meals. The Plan denied your request. The Plan says the personal care services you are requesting are considered custodial care and are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition services.

You asked the Plan to pre-approve the requested services. You say that the enrollee requires enhanced supportive nutritional therapy. The Plan denied your request. The Plan says the enrollee has no problems with her intestinal tract.

The Plan must follow Medicare rules. Medicare rules say that parenteral nutritional therapy is only covered under certain medical indications. 

We looked at the file and Medicare rules. The records do not show that the enrollee has a severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve intradialytic parenteral nutrition services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Nitro walker.

You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your request. The Plan says a power wheelchair has already been authorized at this time.

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 walker. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have already been approved for a power mobility device to meet your mobility needs. In the provided medical visit note despite an assessment of "mobility impaired," the objective documentation in the physical examination reports the gait to be "steady" and "normal."

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 walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a Nitro walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar-sacral orthosis (L0650).

You asked the Plan to pre-approve a lumbar-sacral orthosis. You say that this item is necessary. The Plan
denied your request. The Plan says the enrollee received a spinal orthosis.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.

The file shows that you have lumbar-sacral orthosis. This orthosis serves the same purpose as a lumbar-sacral
orthosis. There is no evidence that you are unable to continue to use this orthosis for your medical needs.
Therefore, we decided that the Plan does not have to pre-approve a lumbar-sacral orthosis (L0650).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management.

You asked the Plan to pay for hospital discharge day management; more than 30 minutes (99239). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted does not include a hospital discharge day management note with a recorded duration of time 31 minutes or more.

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 CPT Code Manual definition of code 99239 is Hospital discharge day management; more than 30 minutes.

We find that CPT code 99239 is not supported in the medical record. Specifically, the medical record does not show a record of services for 31 minutes or more. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management; more than 30 minutes have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management.
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 a non-healing wound of the right foot and had a right below the knee amputation. Medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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 an expandable controller (E2377, E2313, E2311).

You asked the Plan to pre-approve an expandable controller. You say that the expandable controller is
medically necessary. The Plan denied your request. The Plan says the expandable controller is not medically
necessary for the enrollee.

The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is
medically necessary based on the criteria listed 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 an expandable controller. Our reviewer
says that the requested expandable controller is not medically necessary and reasonable. Our physician
reviewer found the enrollee is a 59-year-old male with a past medical history of multiple sclerosis who requires
a power wheelchair for mobility. Based on the medical records provided there is no documentation that an
expandable controller is medically necessary to accommodate proportional input devices (e.g., mini proportional
or compact joysticks, touchpads, chin control, head control, etc.)/non-proportional input devices
(e.g., sip and puff, head array, etc.)/to operate 3 or more powered seating actuators/to operate a separate
display/other electronic devices (e.g., control of an augmentative speech device or computer through the chair's
drive control)/or an attendant control. The records indicate that the enrollee has adequate strength to control the
power options with their own switches.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan
does not have to pre-approve an expandable controller (E2377, E2313, E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lens fitting (92310).

You asked the Plan to pay for the contact lens fitting. You say that contact lenses improve your quality of life,
therefore the lens fitting should be covered. The Plan denied your request. The Plan says the lens fitting is not
covered under your supplemental benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers a routine eye exam once every 12 months, and routine eye wear, such as glasses or
contact lenses, up to $150 every 12 months.

We looked at the file and the Plan's rules. The Plan contract does not cover contact lens fittings. The Plan has
agreed to cover the routine eye exam and the contact lenses in full, however the contact lens fitting remains
your responsibility. Therefore, we decided that the Plan does not have to pay for the contact lens fitting
(92310).