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

 We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy services.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the wound has not shown any signs of improving since beginning treatments.  The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered under certain medical indications.   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 you have been receiving wound care treatment for the past two months. The records did not show that measurable signs of healing have been demonstrated. The requested treatment is 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy 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 meets criteria for an IRF admission and will not benefit from a lower level of care. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF admission does not meet the requirements for approval.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.   Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS) services (93702).  You asked the Plan to pre-approve BIS services. You say that these services are medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says that the bioimpedance spectroscopy services are not medically reasonable and necessary as they are considered experimental/investigational.   The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve BIS services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that bioimpedance spectroscopy (BIS) is used to assess lymphedema by measuring limb fluid content as an electric current passes through cell membranes and tissues. Bioimpedance spectroscopy is used for diagnosis as well as assessing treatment response.  Bioimpedance spectroscopy (BIS) is an increasingly utilized diagnostic technique that allows for the subclinical detection of lymphedema, prior to clinically evident disease. Early detection allows early treatment for prevention of clinically significant lymphedema. It has become a standard of care. The service is reasonable and 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 BIS services have been met. Therefore, we decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS) services (93702).   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Rhopressa solution.  You asked the Plan to pre-approve self-administered drug. You say that the enrollee needs this medication or will deteriorate. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rhopressa solution.   Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve total knee arthroplasty (TKA) surgery.  You asked the Plan to pre-approve knee arthroplasty surgery. You say that the enrollee has a chronic knee pain condition with end-stage osteoarthritis and has failed conservative treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no contraindication to a course of physical therapy and no injections have been offered.  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 knee arthroplasty surgery. 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 end-stage osteoarthritis of the knee. The records indicate that conservative treatments such as injection and physical therapy were deferred per the enrollee's request in July 2021. The record does not show that conservative treatment were failed or would likely fail. The record does not include primary source documentation of X-Ray results.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee arthroplasty surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve total knee arthroplasty (TKA) surgery.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says your needs can be met at a lower level of care.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that you presented to the acute hospital with altered mental status, fever, vomiting, hypoxia, hypotension and tachycardia. You were treated with intravenous fluids, antibiotics, and corticosteroids. You are non-ambulatory and require total assistance for transfers and activities of daily living. There are no skilled nursing service needs. Although there are skilled therapy service needs, you do not require skilled services on a daily basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued home health skilled nursing visits after December 8, 2021.  You asked the Plan to pre-approve home health. You say that you have a number of wounds on your back and are unable to dress yourself. The Plan denied your request. The Plan says the denial of authorization for additional home health care is correct.  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 home health. Our reviewer says that you do not meet the Medicare criteria for continued home health skilled care. Our physician reviewer found based on the medical records, there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain and/or prevent deterioration. Your pressure ulcer has improved significantly with treatment and the present treatment orders do not require skilled nursing 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 home health have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health skilled nursing visits after December 8, 2021.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says an inpatient rehabilitation 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 a fall and seizure like activity. The enrollee's 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you do not need daily therapy on an inpatient basis.  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 continued services. Our physician reviewer found that you were admitted to a skilled nursing facility after treatment for a right hip fracture. You were reported to be walking 55 feet with contact guard assistance, was at contact guard assist for transfers, and modified independent for activities of daily living. The provided records do not document any medically unstable conditions or the need for treatment with anything other than outpatient medications. There are no skilled nursing service needs. Although there are skilled therapy service needs, you do not require skilled services on a daily basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve mastectomy for gynecomastia (19300).  You asked the Plan to pre-approve mastectomy for gynecomastia. You say that these services are medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that male mastectomy services for gynecomastia are subject to the criteria listed 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 mastectomy for gynecomastia. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found the enrollee is a 78-year-old man with a long history of gynecomastia.   In this case, the documentation does not support that the enrollee's gynecomastia persists more than 3 to 4 months after the pathological causes are ruled out, persists after 3 to 4 months of unsuccessful medical treatment for pathological gynecomastia, or that the enrollee has pain or tenderness directly related to the breast tissue which has a clinically significant impact upon activities, or that excessive breast weight adversely affects the enrollee's supporting structures of the shoulders, neck and trunk.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of mastectomy for gynecomastia have not been met. Therefore, we decided that the Plan does not have to pre-approve mastectomy for gynecomastia (19300).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you no longer require skilled services and the continuation of SNF 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF sevices have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 52 trip limit.  You asked the Plan to pre-approve the additional trips for routine transportation beyond the Plan's limit. You say that you need additional trips to your doctor appointments. The Plan denied your request. The Plan says the requested trips exceed your trip limit.  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 a maximum of 52 trips per year.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you will have exhausted the Plan maximum benefit for coverage of routine transportation with the requested trips. Therefore, we decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 52 trip limit.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for a continuation of SNF care. The Plan denied your request. The Plan says the enrollee does not require a skilled therapist. The Plan says that the enrollee's persistent low level of function means she's not a candidate for continuation of skilled therapy in a SNF.  The Plan says that the enrollee can be safely managed in the home or a long-term care setting with intermittent therapies through home health care services or Part B Medicare therapy services.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  The enrollee appears to have reached a plateau in function.  Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical extractions and anesthesia for surgical extractions.  You asked the Plan to pre-approve surgical extractions and anesthesia for surgical extractions. You say that the services are medically necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical extractions and anesthesia for surgical extractions.