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

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve the CGM. You say that it is difficult for you to do the manual finger stick to measure your glucose due to poor eyesight. You say that you also have poor manual dexterity due to arthritis and it is difficult for you to insert lancet. You say that you are trying to get better control of your diabetes by limiting your intake of sugar and carbohydrates. You say that the requested CGM is medically necessary to prevent your diabetes from getting worse and will aid in the treatment of your medical condition. The Plan denied your request. The Plan says the requested CGM is not medically necessary because the enrollee does not require insulin injections at least three times per day.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 14 hours per week for home health aide services, 15 minutes each (G0156).

You asked the Plan to pre-approve additional home health aide services. You say that you disagree with the decrease in homemaker hours. You say that you require the full 35 hours due to your medical issues. The Plan denied your request. The Plan says the allotted home health aide hours properly meet your needs.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 additional home health aide services. Our reviewer says that the additional home health aide visits are not medically necessary. Our physician reviewer found the provided documentation indicates that you do not have documented, acute, skilled needs. The reviewer found no evidence that five hours per day of commiserate home health aide services are required to assist in the treatment of any acute injury or illness. The reviewer found that your home health aide needs appear to be chronic and custodial. Therefore, the reviewer found that the quantity of requested, home health aide services is not medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health aide services have not been met. Specifically, the file indicates that your home health aide needs appear to be chronic and custodial. Therefore, we decided that the Plan does not have to pre-approve an additional 14 hours per week for home health aide services, 15 minutes each (G0156).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone tablets.

You asked the Plan to pre-approve the Prednisone tablets. The Plan denied your request. The Plan says this drug is never covered by Medicare for the enrollee's condition. The Plan also says that the enrollee has not received a transplant.

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 Prednisone tablets.

Benefits for the Prednisone tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services (G0156) for 28 hours per week, for 9 weeks.

You asked the Plan to pre-approve home health aide services. You say that the services are medically necessary. The Plan denied your request. The Plan says you do not require hands-on help with personal care tasks.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our reviewer says that the requested home health aide services are not medically necessary. Our physician reviewer found the provided documentation indicates the enrollee does not have documented, acute, skilled needs. The documentation does not show that commiserate home health aide services are required to assist in the treatment of an acute illness or injury. The reviewer found that the enrollee's home health aide needs appear to be custodial and long-term. Therefore, the reviewer found that the requested home health aide services are not medically necessary, reasonable or coverable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Specifically, the file shows that the enrollee's home health aide needs appear to be custodial and long-term. Therefore, we decided that the Plan does not have to pre-approve home health aide services (G0156) for 28 hours per week, for 9 weeks.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical management of an abdominal mass, metastatic from primary lung cancer. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).  You asked the Plan to pre-approve these services. 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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of right knee pain, osteoarthritis, and meniscal injury. The requested Coolief RFA for genicular neurotomy is considered experimental/investigational in nature and therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on July 1, 2021.  You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed and approved based on the medical documentation. The Plan denied your request. The Plan says these services are not covered.  The Plan must follow Medicare rules. Medicare rules say that clinical psychology services must be provided by a clinical psychologist with a doctoral degree in psychology who is licensed and certified by the state.  We looked at the file and Medicare rules. The file shows that the provider has an EDD (Doctor of Education) degree and not a doctorate in psychology. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90834) provided on July 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your needs may be met at a lower level of care.    The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee's medical condition requires the IRF level of care. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of an IRF admission does not meet the requirements for approval.  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. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 prosthetic leg with an advanced foot feature (L5981).  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the request for a K3 foot does not meet Medicare criteria as reasonable and 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the treating medical physician provider progress notes do not indicate or support that you are at a K3 functional level. Therefore, the request for a prosthetic leg with an advanced foot feature (L5981) does not meet medically necessary criteria.  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 a prosthetic leg with an advanced foot feature (L5981).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an OON second opinion. You say that you are in need of a second opinion for your diagnosis of breast cancer. The Plan denied your request. The Plan says there are 12 in-network oncology providers within a 20-mile radius of the enrollee's zip code who can provide a second opinion.  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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network (OON) provider.
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 do not want to go to a skilled nursing facility, and you want to have intensive rehabilitation at an IRF before returning home. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You would benefit from ongoing therapy to enhance your rehabilitation potential, but these services can safely 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 with your current medical stability, there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You have no acute rehab nursing needs. At your current functional level, you do not require intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with a multidisciplinary approach to daily therapy. You are frail and cognitively require a lot of assistance and will not tolerate the intensity of therapies provided in an IRF. You will not be able to retain the skills learned to benefit from IRF admission. Your rehab needs can be addressed just as well in a skilled nursing facility, and acute rehab with a short stay will not allow you to gain a level of function that is adequate to go home to live alone. The IRF admission is not medically 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you have no documented need for daily skilled services.    The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional home health skilled nursing services.  You asked the Plan to pre-approve additional home health skilled nursing services. You say that additional home health skilled nursing services are medically necessary. The Plan denied your request. The Plan says additional home health skilled nursing services are not medically necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 additional home health skilled nursing services. Our reviewer says that additional home health skilled nursing services are not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. Although you require assistance with medication management, mobility, transfers and activities of daily living, the records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled nursing visits beyond what have already been approved. In addition, the records indicate that you are getting additional assistance in the home through  Adult Foster Care 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 additional home health skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health skilled nursing services.