Persius/hicric huggingface dataset:
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 the enrollee does not have skilled nursing or rehabilitation needs.  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 from a nursing perspective, the enrollee received oral medications, was treated for a urinary tract infection, and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, the enrollee was at a moderate assist level with functional mobility. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex procedure.  You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested Vertiflex procedure 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 the Vertiflex procedure. 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. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for physical therapy services provided from May 3, 2021, through May 25, 2021.  You asked the Plan to waive the deductible for physical therapy. You say that you were told there was no cost for physical therapy. The Plan denied your request. The Plan says the correct amount was applied to your deductible.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $0 copayment for physical therapy services. However, the contract also clearly says that you must pay a $300 deductible which applies to physical therapy services.   The item or service you asked the Plan to waive the deductible for falls within the Outpatient Rehabilitation Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible which applies to covered services. This cost sharing is a contractual obligation that had not been met at the time physical therapy was received from May 3, 2021, through May 25, 2021. Therefore, we decided that the Plan does not have to waive the deductible for physical therapy services provided from May 3, 2021, through May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve manual wheelchair accessories and seating.  You asked the Plan to pre-approve manual wheelchair accessories and seating. You say that the requested items are medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage of the requested items have not been met.  The Plan follows Medicare rules. Medicare rules say that the requested items are subject to the criteira 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 manual wheelchair accessories and seating. Our reviewer says that the requested items are not medically reasonable and necessary. Our physician reviewer found According to Medicare a manual wheelchair can be medically necessary when the beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming and bathing in customary locations in the home.  The beneficiary's home provides adequate access for maneuvering a manual wheelchair and the beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.  Accessories and seating (transit option, pneumatic propulsion tires, padded trunk strap, Jay union cushion, Acta relief back, Bodilink lateral trunk support and hardware can be considered medically necessary when the beneficiary has a manual wheelchair or a power wheelchair with significant postural asymmetries that are due to specific diagnoses. These diagnoses include a neurological condition, myopathy or congenital skeletal deformity. In this case, the documentation doesn't support that the requested accessories are being ordered for the treatment of a condition causes by a neurological condition, myopathy or congenital skeletal deformity. The requested accessories are not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of manual wheelchair accessories and seating have not been met. Therefore, we decided that the Plan does not have to pre-approve manual wheelchair accessories and seating.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve for acute inpatient hospital care to be provided after an elective shoulder joint replacement surgery.  You asked the Plan to pre-approve for acute inpatient hospital care. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about your condition; your care could be provided without an inpatient stay after your surgical procedure.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care is met in this case. Our physician reviewer found that your medical history and recent clinical assessment showed stability and low risk overall. Therefore, for this typically ambulatory procedure, it would not be expected that you would require hospital services that would likely cross 2 midnights.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided after an elective shoulder joint replacement surgery.
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an inversion table.  You asked the Plan to pre-approve an inversion table. You say that an inversion table is medically necessary. The Plan denied your request. The Plan says an inversion table is not covered by Medicare.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  An inversion table does not serve a purpose that is primarily medical in nature. This item is available to the 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 an inversion table.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve office visits 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 office visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve cardiology visits to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the OON cardiology visits. You say that going to Olean for care is much closer. You say that you have transportation issues and cannot travel far. You say that you do not have transportation to go to Erie. The Plan denied your request. The Plan says care must be received from a network provider. The Plan says that there are 13 network cardiologists within 50 miles of your zip code, and three are within 25 miles of your zip code. The Plan says that there are network cardiologists in Olean.  Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers.   The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from your home who can provide the OON cardiology visits. Under Medicare rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not have to pre-approve cardiology visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve closure of veins in the legs.  You asked the Plan to pre-approve closure of veins in the legs. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that invasive procedures for the treatment of varicose veins are considered medically reasonable and necessary when specific criteria are met.  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 closure of veins in the legs. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation of Clinical, Etiologic, Anatomic and Pathophysiologic (CEAP) clinical classification and the revised Venous Clinical Severity Score (VCSS) or documentation of failure of conservative therapy. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of closure of veins in the legs have not been met. Therefore, we decided that the Plan does not have to pre-approve closure of veins in the legs.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.  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 the enrollee does not meet Medicare criteria for daily inpatient skilled therapy.  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 the enrollee's condition does not meet Medicare criteria for 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a lift chair with a heater and vibration.  You asked the Plan to pre-approve a lift chair with a heater and vibration. You say that the services are necessary. The Plan denied your request. The Plan says the chair component is not a covered item. Based on the documentation provided, coverage criteria have not been met.  The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.  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 lift chair with a heater and vibration. Our reviewer says that the services are not medically necessary. Our physician reviewer found the medical progress notes do include a lift chair in the course of treatment. The seat lift is not likely to (a) effect improvement in your condition; or (b) arrest or retard deterioration in your condition. The records do not show that you are totally incapable of standing from a chair in the home. You are ambulatory. You do not meet the criteria for the seat lift mechanism.  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 lift chair with a heater and vibration have not been met. Therefore, we decided that the Plan does not have to pre-approve a lift chair with a heater and vibration.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve therapeutic facet joint injections.  You asked the Plan to pre-approve therapeutic facet joint injections. You say that these services are medically reasonable and necessary based on extenuating circumstances as documented in the medical records. The Plan denied your request. The Plan says that the criteria for coverage for the requested services have not been met.  The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint injections can be approved only if medial branch blocks (MMB) cannot be performed due to specific documented anatomic restrictions or there is an indication to proceed with therapeutic intraarticular injections.  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 therapeutic facet joint injections. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found that the enrollee is a 74-year-old female with chronic low back pain due to lumbar spondylosis, without myelopathy or radiculopathy and a past medical history of factor V Leiden on chronic Warfarin. Presentation continues to be most consistent with lumbar facet mediated pain. She does have evidence of severe facet arthropathy at the L3-L4 and L4-L5 level in the setting of L5-S1 hemivertebrae, scoliosis and dynamic instability at L4-L5. She does have moderate central stenosis.  According to the coverage rules, intraarticular (IA) facet block(s) are considered reasonable and necessary as a diagnostic test only if medial branch blocks (MMB) cannot be performed due to specific documented anatomic restrictions or there is an indication to proceed with therapeutic intraarticular injections.  The provider documented that due to the enrollee's congenital anatomy/transitional anatomy in the setting of dynamic instability performing an MBB/RFA would be difficult. She is also maintained on anticoagulants and has factor V Leyden which would be further prohibitive to RFA. She has consulted with neurosurgery and they recommended interventional treatment options. The review has determined that the requested therapeutic facet joint injections are medically reasonable and 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 therapeutic facet joint injections have been met. Therefore, we decided that the Plan has to pre-approve therapeutic facet joint injections.   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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan services.  You asked the Plan to pre-approve the PET scan. You say that you went to Urgent care because you were having chest pains and difficulty breathing. You say that test results showed a lesion on your chest and a mass on your right sternum. You say that the provider recommended a PET scan. You say that your previous primary care physician would not order the PET due to your having filed a grievance against him in the past. You say that you are concerned you may have cancer and want to have the PET scan completed as soon as possible. The Plan denied your request. The Plan says the requested does not include a treating physician's order.  The Plan must follow Medicare rules. Medicare rules say that an attending/treating physician's order is required for each diagnostic test. Medicare rules also say that one FDG PET study is covered for beneficiaries who have cancers that are biopsy proven or strongly suspected based on other diagnostic testing.   We looked at the file and Medicare rules. The case file does not show that a treating physician ordered the requested PET scan. In addition, there is no evidence that the enrollee has a cancer that is biopsy proven or strongly suspected based on other diagnostic testing. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) scan services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve medical nutrition therapy.  You asked the Plan to pre-approve medical nutrition therapy services. You say that this is medically necessary. The Plan denied your request. The Plan says the coverage criteria are not met.  The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.   The records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy.