Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transluminal balloon venous angioplasty.
You asked the Plan to pre-approve transluminal balloon venous angioplasty. You say that the requested transluminal balloon venous angioplasty is medically necessary. The Plan denied your request. The Plan says the requested transluminal balloon venous angioplasty is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve transluminal balloon venous angioplasty. Our reviewer says that the requested transluminal balloon venous angioplasty is not medically necessary. Our physician reviewer found the health plan has already approved the medically necessary arterial interventions requested. This enrollee has clear evidence of limb threatening ischemia and satisfactory documentation of associated arterial occlusive disease, and the plan for angiography and possible intervention
is both appropriate and medically necessary. At issue is that there was also a code requested for venous angioplasty. As there was no mention in the medical record of a venous disorder requiring treatment and no mention of any plan for venous treatment by the provider, this specific code was appropriately denied. It is highly possible that this was merely a clerical error. There should be no delay in the enrollee proceeding with the medically necessary and covered arterial interventions in unnecessary efforts to appeal the venous code. It is possible that the medical provider is not even aware that there is a possible delay due to this venous code issue. Recommend proceeding with the arterial intervention without delay. However, the requested venous angioplasty 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 transluminal balloon venous angioplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve transluminal balloon venous angioplasty
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a safety belt/pelvic strap (E0978) and a crutch/cane holder (E2207).
You asked the Plan to pre-approve a safety belt/pelvic strap (E0978) and a crutch/cane holder (E2207). You say that the requested safety belt/pelvic strap (E0978) and crutch/cane holder are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested safety belt/pelvic strap (E0978). The Plan also says a crutch/cane holder is not covered by Medicare or the Plan.
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 safety belt/pelvic strap (E0978). Our reviewer says that the enrollee does not meet criteria for the requested safety belt/pelvic strap (E0978). Our physician reviewer found a safety belt/pelvic strap (E0978) is covered if the beneficiary has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning. The case file does not contain documentation that the enrollee has weak upper body muscles, upper body instability or muscle spasticity which requires use of a safety belt/pelvic strap for proper positioning. The rules also say that for equipment to be covered, it must primarily serve a medical purpose. The crutch/cane holder (E2207) 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. 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 safety belt/pelvic strap (E0978) and a crutch/cane holder (E2207) have not been met. Therefore, we decided that the Plan does not have to pre-approve a safety belt/pelvic strap (E0978) and a crutch/cane holder (E2207).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the continued SNF care. You say that the records provided support the need for continued SNF care. The Plan denied your request. The Plan says the records show the enrollee's functional abilities have improved during the SF stay and he is now able to ambulate 200 feet with a rolling walker and with contact guard assistance. The Plan says that the enrollee requires standby assistance for transfers and his medical conditions have been stable. The Plan says that the enrollee no longer requires skilled services on a daily basis and the continuation of SNF care is not medically necessary.
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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for pain. The enrollee received physical therapy, occupational therapy, and speech therapy. By the dates in question, the enrollee was at a standby assist to contact guard assist level with functional mobility, including gait. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a bioimpedance spectroscopy (BIS) assessment using the ImpediMed L-Dex testing device.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no scientific research that documents the long-term effectiveness and improvement of outcomes for the treatment of breast cancer.
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 the testing. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the evidence suggests that monitoring with bioimpedance spectroscopy (BIS) allowing for early intervention significantly reduces the relative risk of chronic breast cancer-related lymphedema (BCRL) with a 69% and 81% reduction compared to background and circumference, respectively. Circumference monitoring did not appear to provide a benefit with respect to chronic BCRL incidence. Based on these results, BIS should be considered for BCRL screening in order to detect subclinical BCRL and reduce rates of chronic BCRL, particularly in high-risk patients. 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 been met. Therefore, we decided that the Plan has to pre-approve a bioimpedance spectroscopy (BIS) assessment using the ImpediMed L-Dex testing device.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to improve after a prolonged hospital course and needs rehabilitation. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the services they need in a less intensive 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 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. 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 this 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 15, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that you are not safe to be discharged as you do not have anywhere to go. You cannot take care of yourself at this time, and staff are working to have you admitted to an assisted living facility at this time. The Plan denied your request. The Plan says as of November 15, 2021, you no longer meet the criteria for continued inpatient psychiatric care. You have no thoughts of harming yourself or others, you are not seeing or hearing things that are not really there, and you are not aggressive and are compliant with treatment. You can continue services at a less restrictive level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued inpatient psychiatric services appears appropriate in this case. Our physician reviewer found that you were admitted to the acute inpatient psychiatric hospitalization on November 8, 2021, with Major Depressive Disorder, Single Episode, Moderate and Major Neurocognitive Disorder, Unspecified, Mild with Behavioral Disturbance. Based upon review the records provided it was not expected that you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of November 15, 2021, forward and could have been treated in a lesser restrictive 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 continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 15, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-therapeutic CGM (CPT code(s): A9276 X 1, A9277 X 1, and A9278 X 1).
You asked the Plan to pre-approve non-therapeutic CGM. You say that the items are necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 you are not insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump. Your insulin treatment regimen does not require frequent adjustment by you on the basis of BGM or CGM testing results. The records do not show that within six (6) months prior to ordering the CGM, the treating practitioner had an in-person visit with you to evaluate your diabetes control and determined that criteria (1-3) above are met. The rules do not show that every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with you to assess adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of non-therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve non-therapeutic CGM (CPT code(s): A9276 X 1, A9277 X 1, and A9278 X 1).
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 Medicare benefit does not provide for daily skilled services for your set of circumstances.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the requested monitor is not medically necessary.
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 does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, or requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered when provided by a supplier that does not participate in Medicare.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available evidence regarding the MyoPro Motion G device is insufficient to demonstrate that the device is medially reasonable and necessary in this 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G device 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 you would benefit from therapy at a SNF 
since you are not at your prior level of function. The Plan denied your request. The Plan says the enrollee has 
not had a change in function that needs daily skilled therapy services in an inpatient SNF. The Plan says that 
there are no daily skilled nursing needs noted. The Plan says that the enrollee's needs may be met at an alternate 
level of care. 
 
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 SNF services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs.  The enrollee does not 
have documented skilled therapy needs.  Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollee's condition.  The enrollee's care needs, as a 
practical matter, can be provided at a lower level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a patient lift.
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your
request. The Plan says the documentation does not show that the enrollee cannot transfer between bed, chair,
wheelchair, or commode without the use of this lift.
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 lift. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation doesn't support that you require a mechanical lift for transfers or that you would be
bed bound without a mechanical lift. You are able to move all of your extremities. Furthermore, the
documentation indicates that you would only use the lift intermittently.
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 lift have not been met. Therefore, we decided that the Plan does not have to
pre-approve a patient lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473).
You asked the Plan to pre-approve the removal of torus mandibularis (D7473). You say that the services should be covered under the Plan. The Plan denied your request. The Plan says the service is not a covered benefit.
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-approve the removal of torus mandibularis (D7473).