Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair for the enrollee.You asked the Plan to pre-approvethe wheelchair. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medically necessary.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. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the enrollee has a personal mobility deficit but the records do not clearly indicate that this deficit impairs participation inMRADLs in the home. The documentation does not reveal support that the patient's mobility deficit is unable to be helped by a walker or manual wheelchair. A September 2019 progress note did not reveal a neurologic exam or detailed upper extremity evaluation or gait evaluation. On a Nov. 2019 letter of necessity she was noted to have no upper extremity limitations in strength or range of motion. She has a slow ataxic gait. The documentation does not reveal a home assessment. Therefore it is not clear if theenrollee would be able to safely operate a PMD in the home.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 wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansayswith continuation of SNF therapies, the enrollee should be able to achieve her prior level of function for home discharge.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy may be more appropriate. It is not clear that you would be able to fully benefit and/or participate in an IRF 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says IRF admission 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 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 that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvePraluent for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested drug is not covered under this plan.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-approvePraluent.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee is at baseline, and does not require skilled care in a SNF setting.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.The file shows that continued services beyond January 1, 2020 were requested. 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 physician reviewer found that the enrollee's current level of function is set-up with grooming, contact guard assist with bathing, maximal assist with colostomy care, standby assist with transfers, contact guard/standby assist with dressing. He is ambulating 150 feet with a wheeled walker with standby assist. There are no noted daily skilled complex nursing needs. He is ambulating household distances, and requires little assistance with mobility and transfers. While he may benefit from continuing physical and occupational therapy, the records do not support the need for daily therapy. He is at/near his baseline level of function.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 continued skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there is no complex medical condition requiring close medical monitoring.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs, and was treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a supervision/stand by assist to contact guard assist level with functional mobility. The enrollee required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal assistant services.
You asked the Plan to pre-approve personal assistant services. You say that The Plan denied your request. The Plan says your function level no longer meets the requirements to receive personal attendant services.
The Plan must follow Medicare rules. The rules say that custodial care is not covered. The Plan offers a personal assistance benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Medicare does not cover the requested services. We found no exception which would require the Plan to cover the services. Therefore, we decided that the Plan does not have to pre-approve personal assistant 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 SNF services. The Plan denied your request. The Plan says that the enrollee does not need at least one therapy service every day for one to two hours for five days a week.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued 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 continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 coveredonly 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 submitted records show that you were admitted to the hospital on December 25, 2019. Te physical therapy notes from December 30, 2019 and December 31, 2019 state you need assistance with sitting up to lying down and standing up to sitting down. You are able to walk 70 feet with a wheeled walker. You have no complex medical, nursing, or rehabilitation needs that require inpatient monitoring at an IRF. You may benefit from further therapy but do 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 beenmet.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveSynjardy 12.5-1,000 mg tablet for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysdrug coverage is limited to Medicare Part B covered drugs.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-approveSynjardy 12.5-1,000 mg tablet for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve admission to an inpatient rehabilitation facility (IRF).You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says therapy needs can be met in a skilled nursing facility.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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 admission have not been met.Therefore, we decided that the Plandoes not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysat the present time, medical care is ongoing, and the current amount of therapy is appropriate to meet your needs.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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR).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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacral nerve stimulator (Interstim) (64590 and 64581) for the enrollee.
You asked the Plan to pre-approve a sacral nerve stimulator (Interstim). You say that the requested sacral nerve stimulator is medically necessary. The Plan denied your request. The Plan says the requested sacral nerve stimulator does not meet criteria.
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 a sacral nerve stimulator (Interstim). Our reviewer says that the requested sacral nerve stimulator does not meet criteria. Our physician reviewer found the enrollee is with a diagnosis of urge incontinence with an overactive bladder. The enrollee recalled that she tried myrbetriq without much improvement. Botox has been helpful for months at a time. The enrollee's medication list on 10/25/19 did not include a drug for treating urge incontinence. A peripheral nerve evaluation resulted in a good response. The documentation in the case file does not support that the enrollee in this case has been refractory to conventional therapy such as behavioral, pharmacologic, and/or surgical corrective therapy. The documentation of pharmacologic failure is limited, and the enrollee is not currently on any medication for urge incontinence.
In addition, there is not adequate demonstration of a recorded voiding diary so that the clinical results of an implant procedure can be properly evaluated. 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 sacral nerve stimulator (Interstim) have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacral nerve stimulator (Interstim) (64590 and 64581) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.You asked the Plan to pre-approve Prolia. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that the member does not meet the plan's medical necessity guidelines.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. The enrollee is noted to have osteoporosis based on the t-score provided on a May 2019 bone density test. There is no documentation that the enrollee's calcium or vitamin D levels have been tested, or that the enrollee is taking calcium and vitamin D supplements. There is no documentation that the enrollee has not responded to or been found to be intolerant of other forms of osteoporosis medication. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Prolia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for Charcot-Marie-Tooth disease for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the medical literature shows that gene testing for someone who already has a diagnosis of Charcot-Marie-Tooth disease will not change medical management.
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 testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is believed to have Charcot-Marie-Tooth disease (CMT). Diagnosis is usually based on the results of physical examination, electromyography, nerve conduction studies and/or nerve biopsy. Genetic testing can identify the root cause of some forms of CMT, but it is not always diagnostic. Furthermore, there is no specific treatment for CMT, regardless of identifying a genetic cause for the disease. As such, the requested genetic testing is not medically necessary or reasonable to further manage 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing for Charcot-Marie-Tooth disease for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve12 teeth extractions (D7140) to be provided.You asked the Plan to pre-approvethe extractions. You say that your teeth broke off during chemotherapy treatments and you need to have oral surgery to get 12 teeth extracted.The Plan denied your request. The Plan says this service is not a covered benefit as the enrollee is getting extractions in preparation for dentures.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve12 teeth extractions (D7140) to be provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea wheelchair ramp to be provided by "the provider".You asked the Plan to pre-approvea wheelchair ramp. You say that you need a ramp to get in and out of your house in your wheelchair.The Plan denied your request. The Plan says wheelchair ramps are not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal 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. Medicare does not cover home modifications.Wheelchair ramps are statutorily non-covered by Medicare. Therefore, we decided that the Plan does not have to pre-approvea wheelchair ramp tobe provided by "the provider".