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

We decided that the Plan does not have to pre-approve a right knee arthroscopy (29875, 29876, 29880, 29881).

You asked the Plan to pre-approve a right knee arthroscopy. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this request is not medically necessary as no imaging service was completed.

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 right knee arthroscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 72-year-old female who was being treated for unilateral primary osteoarthritis, right knee. She had her right total knee performed on October 6, 2020, and has felt like there is something in her knee that clicks or snaps or pops. Exam of the right knee reveals moderate swelling. Diffuse weakness is present, but no discrete motor loss is noted. Motor atrophy includes gluteus and quadriceps and is moderate. Gait is antalgic. Tenderness to palpation is noted at the medial and lateral joint line. There is moderate knee effusion. She has persistent discomfort with pushing off against resistance.

However, detailed documentation is not evident any imaging studies demonstrating pathology on magnetic resonance imaging, x-ray, or bone scan. The requested lab work was not documented to have been performed and/or outcomes provided. Detailed documentation is not evident regarding aspiration injections having been trialed post-surgery. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. In addition, the treatment code requested includes a meniscectomy procedure, and this enrollee has had both of her menisci removed during the arthroplasty. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for right knee arthroscopy (29875, 29876, 29880, 29881) 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 a right knee arthroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a right knee arthroscopy (29875, 29876, 29880, 29881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments.
You asked the Plan to pre-approve a Group 3 power wheelchair and attachments. You say that you fall often and request approval. The Plan denied your request. The Plan says that your records do not show you have a qualifying diagnosis.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve inpatient hospital care. The Plan denied your request. The Plan says the enrollee will not require a greater than 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 inpatient hospital care. Our physician reviewer found that the enrollee has been approved for a total knee arthroplasty. The records do not show the enrollee has a condition that requires an inpatient stay during the approved surgery. There is no documentation provided to support the expectation the enrollee will require a hospital stay spanning 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 inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 16, 2021, forward.

You asked the Plan to pre-approve inpatient psychiatric care from September 16, 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 September 16, 2021, forward. Our reviewer says that you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 16, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond September 16, 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 September 16, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 16, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation and office visit for observation provided on May 5, 2021.
You asked the Plan to pay for the prophylaxis, periodic oral evaluation and office visit for observation. You say that you thought your dental payments for 2021 were included in your automatic monthly payments without having to authorization dental payments each year. You say that you were unaware you had to add the dental rider and want the problem resolved. The Plan denied your request. The Plan says the services are not covered without the additional purchase of the supplemental rider plan.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation and office visit for observation provided on May 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found this 79-year-old was being treated for nondisplaced
fracture of fourth metatarsal bone, right foot; non-displaced fracture of fifth metatarsal bone, right
foot. She sustained a fall down the stairs and fractured her right fourth and fifth metatarsal bone. She was noted
to be non-weight bearing in a controlled ankle movement boot and was noted to follow-up as an outpatient with
orthopedics. While the enrollee does require skilled therapy services, the enrollee does not require skilled
nursing services. In addition, these services are not required on a daily basis. Detailed documentation is not
evident regarding the need for any skilled, daily treatments in this claimant. There is no compelling rationale
presented or extenuating circumstances noted to support the medical necessity of this request as an exception.
Therefore, the request for admission to a SNF (skilled nursing facility) 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panniculectomy.

You asked the Plan to pre-approve a panniculectomy. 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.

The Plan follows Medicare rules. Medicare rules say that this surgery is considered reconstructive when it is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigo dermatitis (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing). 

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 panniculectomy. Our reviewer says that the services are not medically necessary. Our physician reviewer found [in this case the record indicates that the enrollee has a pannus over an old caesarean section scar and has intertigo that has failed to respond to topical treatments. The record does not document that the pannus extends below the level of the pubic symphysis. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

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 panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a panniculectomy.
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 need inpatient rehabilitation services to regain your strength and recover fully. The Plan denied your request. The Plan says that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a Vertiflex Superion device.
You asked the Plan to pre-approve these services. You say that you are in a lot of pain. The Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a Vertiflex Superion device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 17, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from September 17, 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 September 17, 2021, forward. Our reviewer says that you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 17, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond September 17, 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 September 17, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 17, 2021, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to an LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to an 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 is receiving acute hospital care, and acute care services have not been
denied. The documentation does not support that the enrollee in this case requires services at the LTACH that
are not available at the acute care hospital where he is currently receiving care. The documentation does not
support that an additional 25 days of hospitalization are reasonably expected for the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH 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 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 based on review of the available records, you do not meet criteria for an IRF admission. There is no medical complexity, and no documentation of any rehabilitation nursing needs. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Your rehabilitation needs can be met at a less intense and alternate level of setting such as in a 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The imaging study provided is from June 2020 and does not report compression fractures that are noted in progress notes more recently. The record indicates that the enrollee has a body mass index of greater than 40. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan (J9312).
You asked the Plan to pre-approve Rituxan. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Rituxan. Our reviewer says that the requirements for coverage of Rituxan have not been met. Our physician reviewer found the Plan requires a trial of Humira, Enbrel, Xeljanz, or Rinvoq before they will approve the requested drug. The submitted records do not indicate that the enrollee has tried these drugs or that these drugs would likely be less effective or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan (J9312).
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 an LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to an 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 is receiving appropriate care at the present acute care hospital. 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. 

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.