Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient psychiatric admission from September 19, 2021 forward.

You asked the Plan to pre-approve a continued inpatient psychiatric admission. You say that you would like the continued inpatient admission covered. The Plan denied your request. The Plan says under Medicare guidelines, the request is not medically necessary because the records received show that the enrollee's condition has improved, and he is no longer a threat to himself or others.

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 a continued inpatient psychiatric admission. Our reviewer says that the inpatient psychiatric admission from September 19, 2021, forward is not medically reasonable and necessary. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond the dates in question as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. 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 the enrollee's condition or for the purpose of diagnosis. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment from September 19, 2021, forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety.

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 continued inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric admission from September 19, 2021 forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker.

You asked the Plan to pre-approve these services. You say that the walker is needed for the enrollee to get out
and walk without losing his breath. The Plan denied your request. The Plan says the services are not covered.

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. Therefore, we decided that the Plan does not
have to pre-approve a walker.
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. The Plan denied your request. The Plan says you have no acute medical or complex rehabilitation 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 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 physician reviewer found that you have a past medical history of coronavirus with hypoxemia, orthostatic hypotension and diabetes. You are living at home with persistent weakness and debility despite home health physical therapy services. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program.

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 heavy-duty hospital bed (E0303).

You asked the Plan to pre-approve the hospital bed. You say that this is needed so that the enrollee can rest well. The Plan denied your request. The Plan says the weight guidelines for this bed were not followed.

The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed coded with E0303 is covered if the patient's weight is more than 350 pounds, but less than 600 pounds. 

The case file indicates that your weight is under 350 pounds. Based on this information, we decided that Medicare rules for coverage of the hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty hospital bed (E0303).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve screening computed tomographic colonography (CTC).

You asked the Plan to pre-approve screening computed tomographic colonography (CTC). You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested
services are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that screening computed tomographic colonography
(CTC) is non-covered.

We looked at the file and Medicare rules. Review of the file shows that you are requesting screening CTC. This
is specifically not covered. Based on this information, we decided that Medicare rules for coverage of
screening computed tomographic colonography (CTC) have not been met. Therefore, we decided that the Plan
does not have to pre-approve screening computed tomographic colonography (CTC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller
and two or more power seating system motors and a manual swingaway.

You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more
power seating system motors and a manual swingaway. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested items are not covered.

The Plan must follow Medicare rules. Medicare rules say that expandable controllers and swingaways are only
covered for certain indications.

We looked at the file and Medicare rules. Review of the file shows that you are requesting an electronic
connection between wheelchair controller and two or more power seating system motors. The documentation
does not support a medical need to control power options through the joystick. The documentation shows that
the enrollee is able to feed independently and has upper extremity strength of 3 out of 5. This upper extremity
function is adequate to control the power options using their own switch which are included in the allowance of
the approved power options. You are also requesting a manual swingaway identified with code E1028. This
code is unbundled and is included in the allowance of residual limb support system for wheelchair identified
with code E1020 and is not reimbursed separately.

Based on this information, we decided that Medicare rules for coverage of an electronic connection between
wheelchair controller and two or more power seating system motors and a manual swingaway have not been
met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between
wheelchair controller and two or more power seating system motors and a manual swingaway.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in tub.

You asked the Plan to pre-approve these services. You say that the tub is needed to reduce fall risk. The Plan
denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a walk-in tub.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second custom manual wheelchair.
You asked the Plan to pre-approve a second custom manual wheelchair. You say that it was recommended that
you have a second back up wheelchair. The Plan denied your request. The Plan says the requested item is not a
covered benefit.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have a custom manual wheelchair. Your current custom manual wheelchair serves the
same purpose as a second custom manual wheelchair. Review of the file shows that your current manual
wheelchair has a flat tire. The Plan has approved repairs to your current manual wheelchair and a loaner while
your wheelchair is being repaired. Therefore, we decided that the Plan does not have to pre-approve a second
custom manual wheelchair
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion, drug and pump analysis to be provided by an out-of-network provider.

You asked the Plan to pre-approve home infusion/specialty drug administration (99601), hydromorphone injection (J1170) and electronic analysis of programmable implanted pump (62368, 62369) from an out-of-network provider. You say that you need this equipment and supplies for you medications. The Plan denied your request. The Plan says the out-of-network provider you are requesting is over 150 miles from your home.

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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve home infusion, drug and pump analysis to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.

You asked the Plan to pre-approve an office visit. You say that you would like approval for a second opinion.
The Plan denied your request. The Plan says there are in-network providers available for these services.

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
an office visit to be provided by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records provided daily skilled services are not required. You do not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 

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 not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued homecare services/skilled nursing wound care.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical necessity is not established.

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 the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, the documentation doesn't support that you require additional skilled nursing services to provide treatment that is medically necessary. You do not require skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition or perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 

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 continued homecare services/skilled nursing wound care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair elevator.

You asked the Plan to pre-approve these services. You say that you have severe arthritis in both knees and
lower back and can't walk more than 25 to 30 feet without pain. The Plan denied your request. The Plan says
the services are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we
decided that the Plan does not have to pre-approve a stair elevator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network ophthalmologist.
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 available from network providers.
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 referral to an out-of-network ophthalmologist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Cologuard test.

You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your
request. The Plan says the requirement is an age between 50 and 85 years old.

The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered for patients
between 50 and 85 years old.

The file shows that you are 88 years old. Based on this information, we decided that Medicare rules for
coverage of the test have not been met. Therefore, we decided that the Plan does not have to pre-approve the
Cologuard test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this item is not covered under Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued acute inpatient hospital services from
September 16, 2021, onward.
You asked the Plan to pre-approve continued inpatient care. You say that the enrollee is not safe at home and
requires additional hospital care and monitoring for their new medication. You feel the enrollee was discharged
too early from their initial hospital stay and needs additional care. The Plan denied your request. The Plan says
an inpatient hospital admission is not medically necessary fort his enrollee. The requested services are medical
and custodial in nature and can be provided in another 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 continued inpatient care. Our reviewer
says that the requested continuation of care is not considered medically reasonable and necessary in this case.
Our physician reviewer found there were no other treatment or monitoring needs identified that would require
an inpatient admission. The attending physician has indicated that he agreed the enrollee did not require acute
hospitalization from September 16, 2021, onward, and that the enrollee could receive services outside of the
acute care hospital.
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 care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued acute inpatient hospital services from September 16, 2021, onward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Simponi Aria for the enrollee.
You asked the Plan to pre-approve Simponi Aria. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of Simponi Aria in the setting of Systemic lupus erythematosus and autoimmune vestibulocochlear disease has not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Simponi Aria. Our reviewer says that Simponi Aria is not medically reasonable and necessary for the enrollee. There is no documentation that Simponi Aria is FDA-approved for the enrollee's diagnosis. The use of Simponi Aria is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal for systemic lupus erythematosus and autoimmune vestibulocochlear disease. The Medicare-approved major drug compendia have no reference to the use of Simponi Aria for systemic lupus erythematosus and autoimmune vestibulocochlear disease. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Simponi Aria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not have to pre-approve Simponi Aria for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recumbent bicycle.

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 covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a recumbent bicycle.