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

 We decided that the Plan does not have to pre-approve a MyoPro orthotic device.  You asked the Plan to pre-approve the requested device. You say that this is the only treatment that can deliver more intensive practice. The Plan denied your request. The Plan says further research is needed to determine whether the device offers a significant benefit in comparison with conventional treatments.  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 requested device. Our physician reviewer found that the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Therefore, the requested device is considered not medically reasonable or 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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve cardiac monitoring services.  You asked the Plan to pre-approve the requested services. You say that the enrollee's quality of life is decreasing.  The Plan denied your request. The Plan says the enrollee is well-managed with the current regimen.  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 requested services. Our physician reviewer found that the requested implantable loop recorder (ILR) is implanted to guide clinical management in the evaluation of symptoms thought to have a possible arrhythmic etiology. ILR use has been suggested as having a potential role in risk stratification in the evaluation of patients with severe left ventricular dysfunction or inherited arrhythmia disorders, to assess possible need for an implantable defibrillator or pacemaker. This enrollee is asymptomatic, has normal left ventricular function and does not have an inherited arrhythmia disorder. In summary, there is insufficient clinical evidence to support the medical appropriateness and necessity of replacing his old device with a new one.  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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve cardiac monitoring 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 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's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level 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 acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF and their care cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  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 the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require - or be able to tolerate - 15 hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at a lower level of care such as skilled nursing 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 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 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 you are receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan  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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the intermittent limb compression device (E0651).  You asked the Plan to pre-approve the intermittent limb compression device. You say that this durable medical equipment is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the documentation provided is insufficient for the requested equipment.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, the medical records provided do not provide proof that the provider has discussed the medical need for the requested equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pre-approve the intermittent limb compression device (E0651).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Fluorescence in situ hybridization (FISH) testing provided on February 9, 2021 billed with code 88120.  You asked the Plan to pay for the FISH testing. You say that this was medically necessary testing. The Plan denied your request. The Plan says this was done for screening purposes and is not covered by 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 pay for the FISH testing. Our reviewer says that the provided testing is not considered medically reasonable and necessary in this case. Our physician reviewer found FISH testing is considered experimental/investigational as a screening test for urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of FISH testing. Urinary biomarker tests such as FISH testing give significant false-negative results in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. This is not currently considered reasonable and necessary 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 the FISH testing have not been met. Therefore, we decided that the Plan does not have to pay for the Fluorescence in situ hybridization (FISH) testing provided on February 9, 2021 billed with code 88120.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).  You asked the Plan to pre-approve Vertiflex. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is considered experimental/investigational.  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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental/investigational. More research is needed to show the safety and efficacy of the device.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an artificial larynx to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an artificial larynx to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.  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 artificial larynx 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 long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready to be discharged from the current facility and needs to continue their care at an LTACH. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving medically necessary acute and/or critical care at the current facility. The enrollee does not have clinical conditions which cannot be appropriately treated in the current hospital, and there are no issues for which an LTACH may offer a therapeutic advantage. The Plan will continue to cover medically necessary acute/critical care at the current facility until the enrollee is stable to be transferred to a lower level of care or until the clinical circumstances change such that an LTACH may be reconsidered.  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 there is no documentation provided indicating medical necessity for LTACH services. 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 they are 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve routine transportation trips.  You asked the Plan to pre-approve the routine transportation trips. You say that your doctor has advised that you are not allowed to drive while on the medication used for cancer treatment. You say that the requested transportation services are medically necessary. The Plan denied your request. The Plan says the requested transportation services exceed the benefit limitations for routine transportation trips.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles.  We looked at your request, the records in the case file, and the rules. The records show that the routine transportation trips being requested are to a location that is more than 50 miles from your home address. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 29, 2021, forward.  You asked the Plan to pre-approve inpatient psychiatric care from November 29, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  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 inpatient psychiatric care from November 29, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of November 29, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond November 29, 2021, as you were not a danger to yourself 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 your condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from November 29, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 29, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.  You asked the Plan to pre-approve a Dexcom G6 continuous glucose monitor. You say that you are worried about sleeping with the Plan's preferred continuous glucose monitor. The Plan denied your request. The Plan says it is not necessary for you to use a non-preferred monitor.  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 a Dexcom G6 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.  You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee resides in a SNF.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.   Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from May 17, 2020, through May 23, 2020.  You asked the Plan to pay for the SNF services. You say that you have submitted records and a completed SNF worksheet calculation to show that the code billed is correct. The Plan denied your request. The Plan says there is no MDS assessment for this stay. As such, payment cannot be made at the billed level.  The Plan must follow Medicare rules. Medicare rules say that the MDS assessment must be entered into the CMS QIES ASAP system and must be completed and submitted within certain time frames.   In this case, although the calculation worksheet was filled out, a full electronic copy of the MDS assessment as entered into the QIES ASAP system was not included. The calculation worksheet was not signed or dated and did not clearly document the Assessment Reference Date (ARD). The MDS assessment must be completed and signed by a clinician of the facility within 13 days of entering the facility and must be submitted to the system within 7 days of completion. We do not see that this occurred. Without a full copy of the MDS form with sections A through Z filled out, we find that the documentation rules for this SNF stay have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from May 17, 2020, through May 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that this is needed to help mitigate constant and extreme pain while walking. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.