Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone growth stimulator.
You asked the Plan to pre-approve the requested services. You say that the enrollee is an active smoker which will delay the healing process of the fracture. The Plan denied your request. The Plan says a minimum of 90 days has not occurred.
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased. Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for inpatient admission for a planned shoulder
arthroplasty for the enrollee.
You asked the Plan to provide coverage for inpatient admission for a planned shoulder arthroplasty. You say
that at the time of the appeal, inpatient admission was medically necessary. The Plan denied your request. The
Plan says Medicare coverage criteria were not met. We overturned the Plans denial. The Plan requested a
reopen and stated we did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for inpatient
admission for a planned shoulder arthroplasty. Our Physician Reviewer determined the request to be
medically appropriate. The Plan argues in reopen that this was an elective procedure and is not on the"
Inpatient Only" list. The Plan states the enrollee could have been initially monitored within the ambulatory or
observation setting. The Plan states, "Starting the procedure as an ambulatory procedure does not prevent the
attending physician from changing to inpatient status based upon any operative or post-operative concerns."
The medical records show the enrollee had severe osteoarthritis of the left shoulder; a total shoulder
arthroplasty was planned. The enrollee's medical history was notable for coronary artery disease (2018), acute
kidney failure from NSAIDs (2019), hypertension, anemia, smoking, and hyperlipidemia. On August 26, 2021
the orthopedic surgeon wrote, "The need to spend a minimum of one night stay at the hospital is due to
perioperative antibiotics, pain control, postoperative monitoring/care. In addition, the patient has a host of
medical conditions that should be monitored post-operatively."
Our Medical Director has concluded that the Plan is correct in this case. The clinical documentation does not
demonstrate that the admitting physician reasonably expected that the patient's necessary hospital care would
span at least two midnights. It is not documented that the enrollee had serious, uncontrolled medical conditions
that would require inpatient admission. 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 admission for a planned
shoulder arthroplasty have not been met. Therefore, we decided that the Plan does not have to pay for inpatient
admission for a planned shoulder arthroplasty for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and BRCA 2 testing.
You asked the Plan to pre-approve BRCA 1 and BRCA 2 testing. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that BRCA 1 and BRCA 2 testing is only 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 BRCA 1 and BRCA 2 testing. Our
reviewer says that the documentation does not support that the requested services are medically reasonable or
necessary. Our physician reviewer found you have no personal history of breast/ovarian/fallopian tube, primary
peritoneal, or pancreatic cancer. There is no documentation of any signs or symptoms of cancer. You have a
family history of breast cancer mother, pancreatic cancer - brother, head and neck cancer -maternal
grandmother. The documentation does not support that you have a diagnosis/condition that meets criteria for
the requested services.
Review of the file shows that the Plan uses Local Coverage Determination (LCD) L36163 to support their
denial. However, LCD L36163 is not covered for your home state of Pennsylvania. This means we are unable
to use LCD L36163 to substantiate our decision.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of BRCA 1 and BRCA 2 testing have not been met. Therefore, we decided that the
Plan does not have to pre-approve BRCA 1 and BRCA 2 testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient psychiatric admission.

You asked the Plan to pre-approve an inpatient psychiatric admission. The Plan denied your request. The Plan says an inpatient psychiatric admission 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 an inpatient psychiatric admission.

Our reviewer says that an inpatient psychiatric admission is not medically necessary and reasonable. Our physician reviewer found that based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. The health Plan's denial of continued inpatient psychiatric services is appropriate. This 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 the records provided for the admission of this enrollee does not meet the criteria for November 15, 2021 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 the 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 an inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the $5 copayment charged for a physician visit provided on
December 23, 2020.
You asked the Plan to waive this copayment. You say that this was your annual exam and a pneumonia shot
and should be free of charge. The Plan denied your request. The Plan says this copayment was charged based
on the claim submitted by your provider. We overturned the Plans denial because the case lacked a 2020
Plan contract. The Plan requested a reopen and provided a copy of the required contract.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay $5 copayment for each
physician visit. This was an annual exam which included a pneumonia shot.
The pneumonia shot itself is covered at no charge, however, because administration of this shot is beyond the
scope of the free services listed in the annual visit, your provider is within their right to charge for an office
visit for services provided beyond those listed as covered.
You have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the $5 copayment charged for a physician visit provided on December 23, 2020.
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. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.

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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second set of diagnostic spinal injections.

You asked the Plan to pre-approve a second set of diagnostic spinal injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a second set of diagnostic spinal injections is only covered when after the first diagnostic facet joint procedure, there is a consistent positive response of at least 80% relief of primary pain. 

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 second set of diagnostic spinal injections. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the documentation shows that the enrollee received a 30% improvement following the first injection. Therefore, the enrollee does not meet criteria for the requested second set of injections. 

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 second set of diagnostic spinal injections have not been met. Therefore, we decided that the Plan does not have to pre-approve a second set of diagnostic spinal injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that the enrollee needs surgical repair. The Plan denied your request. The Plan says the requested services can be provided by in-plan 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve surgery services 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 IRF care will give the enrollee a higher chance of returning to maximum function and a lower chance of readmission to the hospital. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 the enrollee 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not need daily skilled therapy or nursing services.

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 you presented to the acute hospital with confusion, missed dialysis, and coronavirus infection. You are non-ambulatory and are at a maximum assist level for transfers and activities of daily living. You are reported to be not progressing with physical therapy and are inconsistently following commands. The records indicate your present functional status is your recent baseline. You are reported to be medically stable for discharge on outpatient medications with arrangements for outpatient dialysis. There is no documentation that you require skilled nursing or therapy services on a daily 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) supplies.

You asked the Plan to pre-approve CPAP supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for continued use of a CPAP device.

The Plan must follow Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP =4 
hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) 
months of initial usage.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CPAP supplies have not been met. Specifically, there is no documentation indicating adherence to 
therapy. Therefore, we decided that the Plan does not have to pre-approve continuous positive airway pressure 
(CPAP) supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additions to power seating system, harness for upgrade to expandable controller, and expandable controller.

You asked the Plan to pre-approve additions to power seating system, harness for upgrade to expandable controller, and expandable controller.. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are only 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 additions to power seating system, harness for upgrade to expandable controller, and expandable controller. Our reviewer says that the documentation does not support that the requested items are medically reasonable or necessary. Our physician reviewer found the enrollee has a neurologic disorder with functional deficits. He meets criteria for use of a power mobility device. The requested accessories are not medically necessary as he does have use of his hand and can operate and control the power options using the switches that are included in the basic wheelchair. Furthermore, the documentation does not indicate that the enrollee has lower extremity edema or other condition that would necessitate the use of power elevating leg rests. Therefore, the enrollee does not meet criteria for the requested accessories. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additions to power seating system, harness for upgrade to expandable controller, and expandable controller. have not been met. Therefore, we decided that the Plan does not have to pre-approve additions to power seating system, harness for upgrade to expandable controller, and expandable controller.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits with a contracted tertiary provider.

You asked the Plan to pre-approve office visits with a contracted tertiary provider. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a non-tertiary provider.

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 office visits with a contracted tertiary provider. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the most recent eye examination performed on April 12, 2021 showed that you are complaining of loss of light perception with visual acuity of 20/70; however, no intervention was recommended. The provider advised you to return to office in six months for re-evaluation. The documentation does not support that you meet tertiary guidelines. The documentation shows that your care needs can be adequately provided by a non-tertiary provider.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of office visits with a contracted tertiary provider have not been met. Therefore, we decided that the Plan does not have to pre-approve office visits with a contracted tertiary provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the female external urinary collection device; pouch (A4328), bedside drainage bottle (A5102) and suction pump (K1006).

You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says this item or service is not a covered benefit because it is not reasonable and necessary for treatment of illness or injury nor is it re-usable, it is not medical in nature and it is used for comfort, hygiene and convenience.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve the female external urinary collection device; pouch (A4328), bedside drainage bottle (A5102) and suction pump (K1006).