Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a RN (G0299).
You asked the Plan to pre-approve the direct skilled nursing services of a RN. You say that the enrollee is currently homebound due to considerably taxing effort to leave the residence. You also say that the enrollee needs assistance with all activities and is unable to safely leave home without being helped. The Plan denied your request. The Plan says the current request for care does not require the skills of a licensed nurse.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the direct skilled nursing services of a RN. Our reviewer says that the direct skilled nursing services are not medically reasonable and necessary for the enrollee. Our physician reviewer found there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Our reviewer found that the records do not document an acute change in condition and do not include any reports from the enrollee's treating medical provider indicating the need for additional home health skilled nursing services. Our physician reviewer also found that the provided records do not document why the previously provided home health nursing services have been inadequate 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 direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a RN (G0299).
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 an IRF admission is medically necessary for the enrollee to return to medical baselines. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met.
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 enrollee does not meet CMS coverage criteria for an IRF admission. The enrollee is medically stable. There are no documented skilled nursing needs.
Documentation does not support the need for 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. The enrollee is at high functional level and has no endurance to require IRF level of therapies. An IRF admission is not medically necessary based on lack of medical complexity and lack of skilled nursing needs in addition to high functional level. While he may benefit from physical and occupational therapy, the enrollee's therapy needs can be addressed at a lower intensity level. 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: Favorable

We decided that the Plan has to pre-approve removal/scraping of bone cyst/growth surgery.
You asked the Plan to pre-approve ankle surgery. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this surgery is not medically necessary and conservative treatment has not been documented prior to surgery.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve ankle surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation shows that the enrollee is suffering from a severely painful right foot due to osteoarthritis. It is noted that they have suffered open lesions over this osteoarthritic bone in the past. They are currently wearing an ankle-foot orthosis that is not fitting properly due to the hypertrophic bone of the right foot. The enrollee does meet criteria for this ankle surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ankle surgery have been met. Therefore, we decided that the Plan has to pre-approve removal/scraping of bone cyst/growth surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ultra-lightweight wheelchair (K0009).
You asked the Plan to pre-approve the wheelchair. You say that you are requesting an appeal because you cannot get out or move around the house because you do not have a wheelchair to move around. The Plan denied your request. The Plan says the enrollee does not meet the Medicare coverage criteria because a specialty evaluation was not performed.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The records do not show that you have had a specialty evaluation. Therefore, the criteria has not been met. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve the ultra-lightweight wheelchair (K0009).
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 the SNF admission. You say that the services are medically necessary. The Plan denied your request. The Plan says daily skilled services are not required.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a male with seizure, chronic brain injury, and left hemiparesis, currently in an inpatient rehab facility. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. Regarding rehabilitation services, the beneficiary received physical, occupational, and speech therapy in the acute hospital. The beneficiary was at a minimal to moderate assist level with functional mobility including gait to 60 feet. The beneficiary required varying assist with daily living activities. He had mild cognitive deficits. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, these do not require daily skilled therapy services. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF admission 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen equipment to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve oxygen equipment. You say that there are few durable medical equipment suppliers that carry this product. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this provider is out-of-network with the Plan and an oxygen concentrator can be provided by an in-network supplier.
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 oxygen equipment to be provided by an out-of-network (OON) provider
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 you do not require the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 is medically stable. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day and at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The enrollee's therapy needs can be addressed at a lower intensity level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you believe that IRF care is necessary as a skilled nursing facility will not be able to provide the necessary care. The Plan denied your request. The Plan says the enrollee is medically stable and does not require frequent physician oversight. An intensive therapy program also exceeds his needs
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 is a male who presented to the hospital on 9/4/2021 with syncope.
He was treated in the hospital with lactulose for hepatic encephalopathy and improved. He was also evaluated with a sigmoidoscopy for rectal bleeding and his internal defibrillator was interrogated and confirmed that it had fired for ventricular fibrillation. He had a new ICD lead and battery placed. He is weak and deconditioned and is working with physical and occupational therapy. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the patient requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation 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: Favorable

We decided that the Plan has to pre-approve an implantable loop recorder.
You asked the Plan to pre-approve an implantable loop recorder. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that an implantable loop recorder is covered for certain indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an implantable loop recorder. Our reviewer says that the documentation supports that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has documented atrial flutter seen on stress testing but not on an already completed ambulatory external monitor. Based on the enrollee's history there remains a concern for occult atrial fibrillation which, if found would possibly change the type of ablation procedure being contemplated in this enrollee and the enrollee's long-term medical therapy. In addition, post atrial flutter ablation, the risk of atrial fibrillation increases and the diagnostic yield of an implantable loop recorder as opposed to another external ambulatory device (already negative) is significantly higher, especially when the enrollee already has documented atrial rhythm disturbances. In addition, documenting persistent atrial fibrillation could impact the enrollee's long-term therapy with anti-coagulation as well. This would make the use of the implantable loop recorder medically reasonable and necessary in this clinical circumstance. Therefore, the enrollee meets criteria for the requested 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 an implantable loop recorder have been met. Therefore, we decided that the Plan has to pre-approve an implantable loop recorder.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara (J3357).
You asked the Plan to pre-approve Stelara. The Plan denied your request. The Plan says Stelara is a self-administered drug and is excluded from coverage under Part B.
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 Stelara (J3357).
Benefits for Stelara may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI of the lumbar spine.
You asked the Plan to pre-approve the MRI. The Plan denied your request. The Plan says the records do not show a recent (within three months) six-week trial of conservative treatment that failed to improve the enrollee's symptoms. The Plan also says that the physical therapy records received were focused almost exclusively on treating the enrollee's severe bilateral knee chondromalacia and not his back.
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 MRI is not medically reasonable and necessary for the enrollee. Our physician reviewer found the record indicates that the enrollee has bilateral knee chondromalacia for which he has been receiving treatment. The record indicates that the enrollee now has back pain. Our reviewer found that the physical examination demonstrates decreased range of motion but no neurologic findings. Our physician reviewer also found that no plain films are reported to have been performed and conservative treatment has not been attempted. 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 the MRI of the lumbar spine.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ativan tablets.
You asked the Plan to pre-approve the Ativan tablets. You say that the enrollee has been taking two tablets of Ativan daily since 2010. You also say that with the discontinuation of Ativan the enrollee would have increased anxiety. The Plan denied your request. The Plan says Ativan is a self-administered drug and does not fall under Part B coverage.
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 Ativan tablets.
Benefits for Ativan may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 you do not require the intensity of services provided at an IRF.
Specifically, you do not show to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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.