Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the lateral sacral branches.
You asked the Plan to pre-approve radiofrequency ablation. You say that radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of radiofrequency ablation.
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 radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is experimental/investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the lateral sacral branches.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the orthopedic office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the orthopedic office visit. You say that you are in pain and have been referred to multiple therapy treatments. The Plan denied your request. The Plan says the provider is out-of-network.

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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the orthopedic office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like to work on getting home safely and back to your prior level of function. The Plan denied your request. The Plan says the stay is 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for left hand cellulitis after a cat bite. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the revision of a breast reconstruction surgery to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the revision of a breast reconstruction surgery. You say that the surgery is medically necessary, and you were not aware the surgeon was out-of-network. The Plan denied your request. The Plan says the provider is out-of-network.
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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the revision of a breast reconstruction surgery to be provided by an out-of-network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve SNF services to be provided by the requested out-of-network provider. You say that per the enrollee's daughter, the in-network facilities currently all have Coronavirus, and she will not knowingly send her mother to a facility with Coronavirus. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our Plan you may be required to use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available
(generally, when you are out of the area), out-of-area dialysis services and cases in which the Plan authorizes use of out-of-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 SNF services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve SNF services to be provided by the requested out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network provider. You say that the machine that was used in the contracted provider's office has slowly caused your back pains to return to the previous condition and your physical activity has been severely reduced. The Plan denied your request. The Plan says the services are available in-network and your condition is not an emergency.

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 services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vertiflex superion interspinous device.
You asked the Plan to pre-approve vertiflex superion interspinous device. 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 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 vertiflex superion interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of lumbar spinal stenosis with neurogenic claudication. The vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Therefore, the enrollee does not meet criteria for the requested 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 vertiflex superion interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve vertiflex superion interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300), for the
enrollee.
You asked the Plan to pre-approve the power seat elevation system. You say that the power seat elevation
system is necessary. The Plan denied your request. The Plan says the power seat elevation system is not
primary medical in nature. The Plan must follow Medicare rules. We looked at the file and Medicare rules.
Based on this information, we decided that Medicare rules for coverage of the power seat elevation system
have not been met. The rules say that a power seat elevation feature (E2300) and power standing feature
(E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical
connection device described by code E2310 or E2311 and if the sole function of the connection is for a power
seat elevation or power standing feature, it will be denied as non-covered. Therefore, we decided that the Plan
does not have to pre-approve power seat elevation system (CPT code E2300), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motorized scooter (K0800).
You asked the Plan to pre-approve a motorized scooter. You say that the item is medically necessary. The Plan denied your request. The Plan says there is no documentation that you have had a home evaluation indicating that your home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the requested POV.
The Plan must follow Medicare rules. Medicare rules say that the beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a motorized scooter have not been met. Specifically, there was no documentation submitted indicating your home has adequate access between rooms, maneuvering space, and surfaces for the operation of the requested POV. Therefore, we decided that the Plan does not have to pre-approve a motorized scooter (K0800).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the interspinous process device, for the enrollee.

You asked the Plan to pre-approve the service. You say that the enrollee suffers from severe L4-5 degenerative neuroforaminal stenosis requiring placement of an interspinous process device to prevent recurrent stenosis at that level. You state the enrollee has a neurological deficit of unsteadiness of gait and weakness. The Plan denied your request. The Plan says the services are considered experimental and 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 the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process spinous distraction devices remain experimental. More research is needed to show safety and efficacy.

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 the interspinous process device, for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee has a wound where they reversed their
colostomy. You state the enrollee is partially mobile with walker and has a foley catheter. You state the
enrollee also needs help toileting. The Plan denied your request. The Plan says the stay is 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 considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found 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. The enrollee
was admitted for colostomy reversal. Medical problems are stable. There are no complex nursing or
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and 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. 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six additional skilled nursing visits.
You asked the Plan to pre-approve additional skilled nursing visits. 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 medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve additional skilled nursing visits. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the documentation does not support that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six additional skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary urology consultation.
You asked the Plan to pre-approve a tertiary urology consultation. You say that you are confident that this provider will be able to help you with your prostate cancer diagnosis. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a tertiary urology consultation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have a new diagnosis of prostate cancer. The documentation does not support an indication that other community level urologists are unable to appropriately treat your prostate cancer. In addition, there is no indication that your condition is of such complexity that it requires interdisciplinary or simultaneous treatments with multiple specialty services as part of a complex, coordinated plan of care. Furthermore, the medical records do not show that your condition requires testing or treatment that is otherwise too high of a risk or otherwise not safe to perform at the community level of care. Therefore, you do not meet criteria for the requested tertiary level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tertiary urology consultation have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary urology consultation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF 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 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 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. The enrollee was admitted for exacerbation of congestive heart failure, chronic obstructive pulmonary disease (COPD), pulmonary hypertension, atrial fibrillation, aortic stenosis and had aortic valve replacement by transcatheter aortic valve replacement (TAVR) procedure. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair and a raised toilet seat.

You asked the Plan to pre-approve a shower chair and a raised toilet seat. You say that these items are medically necessary. The Plan denied your request. The Plan says these items are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not covered because they are not primarily medical in nature. 

While a shower chair or raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a shower chair and a raised toilet seat.