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

 We decided that the Plan does not have to pre-approve the group 2 powered pressure reducing air mattress (E0277).  You asked the Plan to pre-approve the group 2 powered pressure reducing air mattress. You say that you would like reconsideration because the requested air mattress is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the requested air mattress.  The Plan follows Medicare rules. Medicare rules say that a group 2 support surface is covered if the beneficiary has multiple stage 2 pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program, if the beneficiary has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis or if the beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days.  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 group 2 powered pressure reducing air mattress. Our reviewer says that the requested pressure reducing support surface is not medically necessary.  Our physician reviewer found the documentation doesn't support that you have multiple stage 2 pressure ulcers located on the trunk or pelvis and have failed to improve in the previous month with conservative treatment with a comprehensive ulcer treatment program or a myocutaneous flap or skin graft.  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 group 2 powered pressure reducing air mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 2 powered pressure reducing air mattress (E0277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. You say that the enrollee should be able to manage their condition at home. The Plan denied your request. The Plan says there are in-network providers that can provide this item.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that SNF services are medically necessary. The Plan denied your request. The Plan says that based on Medicare guidelines, your request for approval of admission to a SNF does not meet the requirements for approval.  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 care. Our reviewer says that SNF services are medically necessary. Our physician reviewer found that based on the limited documentation provided, you do qualify for SNF coverage. You do not have documented skilled nursing needs, though monitoring of your vital signs is reasonable. You do have documented skilled therapy needs. While you are ambulatory, your strength and endurance are below your baseline. You are experiencing hypoxia with activity, despite being on oxygen, which places you at risk for complications (i.e. falls, syncope, tachycardia, respiratory distress.)  A period of daily skilled services is reasonably required to establish a maintenance program or to prevent deterioration of your 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.   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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrocardiogram (ECG) up to 30 days continuous with transmission of patient triggered events with review and report by health care professional (CPT code 93229).

You asked the Plan to pre-approve the service. You say that you got the monitor and did not know your authorization was denied. You state that you have the monitor right now and need this decision overturned as soon as possible. You state your doctor requested this monitor due to your heart and your current condition. The Plan denied your request. The Plan says you did not have an unremarkable 24-hour monitoring session, nor recent continuous telemetry within a hospital that would have reasonably provided the data, given that you were having multiple episodes of palpitations daily.

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 service. Our physician reviewer found it has not been documented that other testing and/or monitoring/recording/telemetry has been unrevealing. It has not been documented that the use of a 24-hour ambulatory ECG is unlikely to capture and record your dysrhythmia.

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve electrocardiogram (ECG) up to 30 days continuous with transmission of patient triggered events with review and report by health care professional (CPT code 93229).
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 disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on December 21, 2021 with Coronavirus infection with pneumonia and had an acute kidney injury that resolved on December 26, 2021. He is now medically stable with a plan for discharge to a skilled nursing facility, per the physician note dated January 17, 2022. With his current medical stability and stable comorbid conditions being stable, he does not need PM&R physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. The IRF admission is not medically necessary based on medical stability and lack of rehab nursing needs.  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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 physical therapy visits.

You asked the Plan to pre-approve 18 physical therapy visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 18 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found in this case, the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition and therefore are 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 18 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 18 physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone growth stimulator.

You asked the Plan to pre-approve a bone growth stimulator. You say that you broke your foot on November 21, 2021. You say that you saw and orthopedic provider on December 14, 2021, and the provider requested a bone growth stimulator. You say that you are an active person, and the bone is not healing. You say that you need to get back on your feet and need the requested device in order to do that. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 

In this case, the file does not show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased. Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator.
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 enrollee is stable and appropriate for transfer to an LTACH. You say that the records provided support the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the care needed in the current hospital setting.

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 was admitted with acute hypoxic respiratory failure due to COVID-19 pneumonia. The record indicates that the enrollee is not clinically stable, experiencing significant oxygen desaturations, and requires ongoing acute care services. The enrollee continues to receive acute care services, and these have not been denied. 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 long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH 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. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital after a fall and was found to have a large intracranial bleed. She was treated and continued to have neurological deficits, including aphasia, which led to a feeding tube placement. She is breathing on her own and no longer requires mechanical ventilatory support. She will continue to receive intravenous antibiotics and hemodialysis. There is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 24 physical therapy (PT) and occupational therapy (OT) visits.  You asked the Plan to pre-approve the PT and OT visits. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollee has reached a plateau in therapy results. The Plan also says that the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 the PT and OT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the provided documentation indicates that the enrollee has had extensive prior therapy for their condition. The reviewer found that the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The reviewer found that the enrollee has been instructed in a home exercise program, safety awareness, posture and body mechanics. The reviewer found that the requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. Therefore, the reviewer found that the physical therapy and occupational therapy visits are 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 the PT and OT visits have not been met. Specifically, the file does not indicate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. Therefore, we decided that the Plan does not have to pre-approve 24 physical therapy (PT) and occupational therapy (OT) visits.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Optimizer Smart permanent cardiac contractility modulation system (CPT code 0408T).  You asked the Plan to pre-approve the service. You say that the system is medically necessary. The Plan denied your request. The Plan says this item or service is not medically necessary because a scientific assessment of the technique has not been completed and its safety and efficacy has not been established.  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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found cardiac contractility modulation has been shown to mildly improve functional measures in patients with heart failure. However, the efficacy and long-term outcomes of this treatment modality have not been established, and there is a significant risk of complications.  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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve Optimizer Smart permanent cardiac contractility modulation system (CPT code 0408T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a cooling vest.  You asked the Plan to pre-approve the vest. You say that this is medically necessary. The Plan denied your request. The Plan says a cooling vest is not considered to be durable medical equipment and not covered by Medicare.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    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 vest. Our reviewer says that the requested vest is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the cooling vest at issue in this case meets Medicare criteria for medically reasonable and necessary. The requested item does not meet the definition of durable medical equipment per Medicare guidelines. The cooling vest is not primarily and customarily used to serve a medical purpose and to treat an illness or injury.  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 vest have not been met. Therefore, we decided that the Plan does not have to pre-approve a cooling vest.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the X-ray exam of chest (71045) provided on September 1, 2021.  You asked the Plan to pay for the X-ray exam of chest. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier.  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, we have confirmed that code 71045 is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray exam of chest (71045) provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).  You asked the Plan to pre-approve the Intracept procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered.  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 Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found published studies do not demonstrate any long-term health outcome advantage with the use of Intracept as an alternative to standard surgical treatment.  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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).