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

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) brain (including brain stem) (70551).

You asked the Plan to pre-approve the MRI. You say that you are appealing the denial of the MRI as the enrollee was seen by neurologist and the neurologist has prescribed medication mentioned in the denial The Plan denied your request. The Plan says that the enrollee does not meet the criteria as the enrollee has not tried taking medication to control tremors and have not been evaluated by a neurologist.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee is suspected of having Parkinson's Disease. A diagnosis of Parkinson's disease is made both on the inclusion of certain findings but also the exclusion of differential diagnoses. It is common and customary to perform an imaging study of the head to rule out any form of intracranial finding/process that could otherwise account for the symptoms that are suspected of being associated with Parkinson's disease. In this context, it can be concluded that the request made in this case would otherwise be reasonable and necessary for the evaluation of the enrollee's condition and as such this would meet Medicare 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) brain (including brain stem) (70551).

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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a folding electric scooter.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 criteria for coverage are not met. Our physician reviewer found the records show that you have a mobility deficit that impairs the completion of mobility-related activities of daily living (MRADLs) in the home. There is a physiatrist evaluation stating you are appropriate for a Group 2 power wheelchair. There is no detailed progress note evaluating your upper and lower extremities with a neuromuscular exam that states you are unable to use a manual wheelchair. Although the physiatrist recommended a Group 2 power wheelchair, the documentation does not contain evidence that the criteria for coverage are met. The device exceeds your needs and is 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a folding electric scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ablation and sclerotherapy for the enrollee.

You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 the procedures. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not meet coverage criteria for sclerotherapy and does not support the medical necessity of these procedures. It is noted that the health plan has already approved the medically necessary left greater saphenous vein ablation. However, there is no evidence that the enrollee is having continued difficulties following saphenous vein ablation (likely has not yet had the ablation). Additionally, there is no evidence that the varicose veins being considered for sclerotherapy are greater than 4 mm in diameter. 

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 procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve ablation and sclerotherapy for the enrollee.
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. You say that you need strength training. The Plan denied your request. The Plan says the services you require can be received in a different setting.

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, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a standby assist to contact guard assist level for functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right shoulder.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has right shoulder pain and weakness. MRI of the right shoulder dated October 18, 2021 showed minimal tendinosis of the supraspinatus and infraspinatus tendons. No other records were submitted that related to a history of right shoulder pain or weakness. No x-rays or physical examinations of the right shoulder were submitted for review. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right shoulder.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve computed tomography (CT) head or brain (70450).  You asked the Plan to pre-approve the CT scan. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says that the records do not support that the requested service is medically necessary.  The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was seen for a regular checkup and reported new dizziness and balance issues after fall at home without injuries. She reported a strange feeling in her head, heaviness, with some memory loss and was diagnosed with amnesia. Due to abnormal neurological findings (impaired finger to nose) and reported memory issues and recent fall, CT head is supported 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 the CT scan have been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) head or brain (70450).   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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve
branches including imaging guidance, when performed (CPT code 64624 X 2) for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan
denied your request. The Plan says there is a lack of literature with true head-to-head comparisons to other
standard treatments.

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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found genicular nerve ablation remains experimental. More research is needed to show safety and
efficacy of the procedure.

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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance,
when performed (CPT code 64624 X 2) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a below the knee prosthesis to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested item.

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 item at issue in this appeal. We found no exception that would require the Plan to pre-approve these item. Therefore, we decided that the Plan does not have to pre-approve a below the knee prosthesis to be rendered by the out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) lower extremity other than joint (73718) magnetic resonance imaging (MRI) any joint of lower extremity (73721).  You asked the Plan to pre-approve the MRI. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records do not support that the enrollee meets the Medicare criteria.  The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation does not sufficiently show that the enrollee has fully exhausted physical therapy and other conservative treatment for her knee pain to justify MRI. X-ray did not suggest a need for follow-up MRI imaging. No planned procedure was noted and there was no pulmonary edema that revealed evidence of a red flag diagnosis to justify MRI without failure of conservative treatment first. Therefore, without sufficient support made for MRI, it will be considered not medically necessary at this time.  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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) lower extremity other than joint (73718) magnetic resonance imaging (MRI) any joint of lower extremity (73721).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro 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 are no records from providers who had treated the enrollee and had recommended
this device.
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 no records are provided other than records from the vendor/manufacturer indicating that the enrollee has
been tested with the device and explained why this is the preferred treatment option for her condition. In
addition, current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-
matched conventional upper limb exercise therapies" with unproven benefit in the home environment.
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 MyoPro device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a brow lift procedure (67900).

You asked the Plan to pre-approve the brow lift procedure. You say that the procedure is medically necessary.
The Plan denied your request. The Plan says coverage criteria has not been met.

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 brow lift procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the photographs provided do not support the need for the brow lift in addition to the
blepharoplasty to treat the enrollee's condition.

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 brow lift procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve a brow lift procedure (67900).
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. You say that these services are medically necessary. The Plan
denied your request. The Plan says that your request does not show you have skilled nursing or therapy needs
that need to be provided on a daily basis as an inpatient only status.
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 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.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you need SNF care to regain maximum function. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Favorable

 We decided that the Plan has to pre-approve an evaluation with a home health agency (HHA).  You asked the Plan to pre-approve the HHA evaluation. You say that you are currently being held in a psychiatric facility, and the attending physician will not release you without having home care set up. You were treated poorly in the facility for which you were treated for emergency hip surgery and were not given any therapy or sufficient pain control. The Plan denied your request. The Plan says that there is no order for home health care. You have not yet seen your primary care physician, and the hospital where you had your surgery has not responded to requests for records. Therefore, home health services cannot be approved.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to obtain medical records from its network facility at which you received surgery. A determination on the medical necessity of skilled nursing or therapy services in the home is not possible without these records, which are deemed to be within the Plan's control. In light of your quality of care allegations, these records are especially necessary. In addition, you state you are admitted to a psychiatric facility, and that the treating doctor wishes you to have home care. The Plan was not able to even confirm that you were admitted or that you are still admitted to this facility and no other information was provided. Without any information on your current status, an approved for any specific set of home health services is not possible; however, since the Plan has failed to obtain records, we find that it is necessary for them to approve an evaluation in order to determine your needs and to allow your treating physician to discharge you, if that is indeed required by them. The denial of an evaluation in this case is not substantiated. Therefore, we decided that the Plan has to pre-approve an evaluation with a home health agency (HHA).   Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.  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.