Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815), for the enrollee.  You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.  The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 the PET scan. Our physician reviewer found it is reasonable and necessary to approve follow-up pet CT to ensure continued response approve per NCD 220.6.17.  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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815), for the enrollee.
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 stable for discharge. You say that the enrollee has had multiple hospitalizations in recent weeks, and due to the enrollee's medical history and current needs, LTACH is more appropriate than returning home or being discharged to a lower level of care. The Plan denied your request. The Plan says the LTACH admission is not medically necessary.  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 that indicates medical necessity for admission to a LTACH. The reviewer found that the enrollee is receiving appropriate care at the present skilled nursing facility (SNF). The reviewer found that the enrollee does not require services at the LTACH that are not available at the SNF where they are currently receiving care. The reviewer also found that 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. Therefore, the reviewer found that 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. Specifically, the file shows that 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. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.  You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the requested service is experimental.  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 Superion Spacer. Our reviewer says that the Superion Interspinous Spacer may be implanted at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. The Food and Drug Administration states that the requested procedure is contraindicated  in individuals with severe osteoporosis.  Our physician reviewer found the record indicates that the enrollee has osteoporosis with compression fractures.  The record indicates that the enrollee has multi-level lumbar disease.  The record indicates that the enrollee has not seen a surgeon. The elements of the coverage criteria are not satisfied.  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 Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 10 additional Occupational Therapy (OT) visits.  You asked the Plan to pre-approve 10 additional OT visits. You say that the requested services are medically necessary. 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 Medicare pays for medically necessary outpatient therapy.  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 10 additional OT visits.  Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found there is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. Based on the available records the enrollee appears to have made no significant improvement with the twenty occupational therapy visits provided thus far. Her most recent therapy records indicate she remains maximum assist to dependent for most activities of daily living despite therapy treatment.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional Occupational Therapy (OT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with components/accessories.  You asked the Plan to pre-approve Group 3 power wheelchair. You say that you need this wheelchair to help with everyday life. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because you do not have a medical need for multiple power options that are included in a K0861 power wheelchair.  The Plan follows Medicare rules. Medicare rules state that a Group 3 power wheelchair with multiple power options may be covered if certain 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 Group 3 power wheelchair. Our reviewer says that you do not meet the Medicare criteria for the requested Group 3 power wheelchair and components. Our physician reviewer found while you do have a qualifying neurologic diagnosis for a Group 3 power wheelchair, the documentation does not reveal that you are at high risk for development of a pressure ulcer, utilize intermittent catheterization for bladder management, or need a power seating system to manage increased tone or spasticity. Therefore, the requested K0861 type power wheelchair with multiple power options exceeds your medical needs.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Group 3 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with components/accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from February 1, 2022, and forward.  You asked the Plan to pre-approve the continuation of inpatient mental health care. You say that the requested continuation of inpatient mental health care from February 1, 2022, and forward is medically necessary. The Plan denied your request. The Plan says the requested continuation of inpatient mental health care from February 1, 2022, and forward is 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 the continuation of inpatient mental health care. Our reviewer says that the requested continuation of inpatient mental health care from February 1, 2022, and forward is not medically necessary. Our physician reviewer found the enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. I am unable to find an individualized treatment plan however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review of the records provided, the enrollee does not meet the criteria for continued inpatient mental health care from February 1, 2022, and forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any 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 the continuation of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from February 1, 2022, and forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for a shoulder arthroplasty for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay.
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 payment are met in this case. Our physician reviewer found a request for hospital admission was made for a shoulder arthroplasty procedure. The provided records did not show the patient as unstable or likely to be unstable following surgery to justify admission. There was insufficient support to suggest the patient 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 an inpatient admission for a shoulder arthroplasty for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network neurologist.
You asked the Plan to pre-approve these services. You say that the enrollee needs to be seen by this provider. 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 neurologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device, humidifier, tubing, nasal interface, and headgear to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve supplies to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available that can provide the items being requested.
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 continuous positive airway pressure (CPAP) device, humidifier, tubing, nasal interface, and headgear to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there appears to be some concern that these services are not as effective as surgical decompression, and could lead to higher rates of reoperation.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the left facet joint steroid and Marcaine injections under imaging guidance.  You asked the Plan to pre-approve the left facet joint steroid and Marcaine injections under imaging guidance. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the limit is no more than 1 to 2 levels, either unilateral or bilateral, per spine region, is injected per session.  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 left facet joint steroid and Marcaine injections under imaging guidance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the coverage criteria, no more than 1 to 2 levels, either unilateral or bilateral, per spinal region, can be injected per session.  The request is for three unilateral cervical levels on the left.   The review has determined that the member does not meet LCD criteria for coverage.  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 left facet joint steroid and Marcaine injections under imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve the left facet joint steroid and Marcaine injections under imaging guidance.
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 you would like reconsideration because the requested IRF care is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the IRF care.
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. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There are no complex nursing or rehabilitation needs. Our physician reviewer found there is not a reasonable expectation that this member 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: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve breast reduction surgery with liposuction.  You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the plan is to remove 300 grams per breast, which is far below the Schnur's scale estimate of tissue removal that would show that the surgery is considered medically reasonable and 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 the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a body surface of approximately 2.1 meters squared. The record indicates that the plan is to remove approximately 300g from each breast. This amount is below the indicated amount according to the Schnur scale. The elements of the coverage criteria are not satisfied.  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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve breast reduction surgery with liposuction.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis 2.5mg oral tablets.  You asked the Plan to pre-approve Eliquis. You say that the enrollee is an ideal candidate for Eliquis and has been taking it since January 2018. The Plan denied your request. The Plan says Eliquis 2.5mg oral tablet is not covered under the enrollee's plan under any normal circumstances. The Plan also says that the enrollee has no Part D benefit or commercial pharmacy plan administered by the Plan.  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 Eliquis 2.5mg oral tablets.   Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.