Persius/hicric huggingface dataset:
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 enrollee requires LTACH services for continuing progress to return to proper level of functioning. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted following a frontoparietal intracranial hemorrhage two weeks after a stroke. The record indicates that the enrollee is extubated. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Electronic Brachytherapy/ IORT (Xoft / AXXENT) (CPT code(s): 77469, 77263, 77424, 77316), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says guidelines do not support the routine use of the requested type of treatment (therapy) for the cancer type. The Plan states that it has not been shown that the enrollee's cancer type has responded well to the requested type of treatment.

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 IORT with electronic brachytherapy is not within accepted standards 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve Electronic Brachytherapy/ IORT (Xoft / AXXENT) (CPT code(s): 77469, 77263, 77424, 77316), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vascular surgery services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the enrollee's network has available 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 vascular surgery services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0861).

You asked the Plan to pre-approve a power wheelchair. You say that the item is medically necessary. The Plan denied your request. The Plan says records show that the enrollee is able to ambulate within their home but has difficulty using their arms with a standard wheelchair. The enrollee has assistance at home for moving with the standard wheelchair. There is no documentation of a face-to-face visit that states the enrollee is unable to meet mobility needs for their ADL's (activities of daily living) in the home with a standard wheelchair. There is also no documentation of a Home Occupational/Physical Therapy visit to determine need for this power wheelchair.

The Plan follows Medicare rules. Medicare rules say that the criteria listed in the Medicare Rules section of this letter must be met for a power wheelchair to be 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 power wheel chair. Our reviewer says that the item is not medically necessary. Our physician reviewer found records show that the enrollee is able to ambulate within their home but has difficulty using their arms with a standard wheelchair. The enrollee has assistance at home for moving with the standard wheelchair. There is no documentation of a face-to-face visit that states the enrollee is unable to meet mobility needs for their ADL's 
(activities of daily living) in the home with a standard wheelchair. There is also no documentation of a Home Occupational/Physical Therapy visit to determine need for this power wheelchair.

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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0861).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) continued stay.

You asked the Plan to pre-approve the SNF stay. You say that you need continued therapy so his condition can progress quickly and get stronger. The Plan denied your request. The Plan says care can be provided at a lower level of care.

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 stay. 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 SNF setting. Therefore, the reviewer found that you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. 

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 stay have not been met. Specifically, the file shows that you do not require skilled care on a daily basis. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) continued stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electronic connector to 2 power options (E2311) .

You asked the Plan to pre-approve the electronic connector to 2 power options. You say that the item is medically necessary. The Plan denied your request. The Plan says Medicare guidance says that upgraded electronics are not medically needed, as there is no medical need to control power options though the joystick.

The Plan follows Medicare rules. Medicare rules state that a power tilt and recline seating system (E1006, E1007, E1008) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface.

A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or without variable speed programmability which allows the legrest to be raised and lowered independently of the recline and/or tilt of the seating system.

It includes a switch control which may or may not be integrated with the power tilt and/or recline control(s). 

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 electronic connector to 2 power options. Our reviewer says that the item is not medically necessary or reasonable. Our physician reviewer found there is not a medical need to control these power options through the joystick. 

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 electronic connector to 2 power options have not been met. Therefore, we decided that the Plan does not have to pre-approve the electronic connector to 2 power options (E2311) .
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.

You asked the Plan to pre-approve facet joint 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 facet joint injections 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 facet joint injections. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a history of low back pain, bilateral lumbar radiculopathy, lumbar
spondylolisthesis, and lumbar stenosis with neurogenic claudication. The enrollee has had pain since December of 2020 and currently use Oxycodone as needed for pain. The enrollee has tried massage therapy and heat/ice/rest to relieve pain and improve his symptoms. The documentation supports radiculopathy. The facet joint injections are limited to patients with pain that is non-radicular. Based on Local Coverage Determination, the review has determined that the enrollee does not have a condition that meets the Medicare criteria for coverage of the facet injection 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate tablets.

You asked the Plan to pre-approve Methotrexate tablets. You say that this is medically necessary. The Plan
denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's
prescription drug plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Methotrexate tablets.

Benefits for Methotrexate tablets 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
April 1, 2021.

You asked the Plan to pay for the dental service. You say that the enrollee had some procedures done that were
not covered. You also say that the enrollee needs them to be covered. The Plan denied your request. The Plan
says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit
has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral evaluation is
listed as a covered, the frequency limit has been exceeded. The record shows that the Plan paid for a
comprehensive oral evaluation that you received on March 5, 2020. Therefore, we decided that the Plan does
not have to pay for the comprehensive oral evaluation (D0150) provided on April 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vertebral augmentation.

You asked the Plan to pre-approve vertebral augmentation. You say that the requested vertebral augmentation
is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the
requested vertebral augmentation.

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 vertebral augmentation. Our reviewer
says that the enrollee does not meet criteria for the requested vertebral augmentation. Our physician reviewer
found the enrollee is with chronic pain syndrome, radiculopathy, and compression fracture of the L1 vertebrae.
Criteria for the requested vertebral augmentation have not been met. There is no documentation and imaging
showing that this is a new fracture. The age of the fracture is unclear.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of vertebral augmentation have not been met. Therefore, we decided that the Plan
does not have to pre-approve vertebral augmentation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint injection.

You asked the Plan to pre-approve a facet joint injection. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage of the requested procedure have not been met.

The Plan follows Medicare rules. Medicare rules say that facet joint injections require an absence of untreated radiculopathy or neurogenic claudification.

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 facet joint injection. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer found specifically there is documentation of radiculopathy. The facet joint injections are limited to patients with pain that is non-radicular. Based on Local Coverage Determination, the review has determined that the enrollee does not have a condition that meets the Medicare criteria for coverage of the facet injection services.

It is not medically necessary or reasonable for this enrollee to have the facet injection services as requested. 

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 facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesiology services for a left radiofrequency
ablation.

You asked the Plan to pre-approve anesthesiology services for a left radiofrequency ablation. You say that you
have never had a nerve ablation without sedation as it is too painful, and you suffer from severe anxiety. The
Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Individual consideration for anesthesia services may
be given on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of
sedation is unequivocal and clearly documented in the medical record.

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 anesthesiology services for a left
radiofrequency ablation. Our reviewer says that the documentation does not support that the requested services
are medically reasonable or necessary. Our physician reviewer found the documentation does not address the
need for monitored anesthesia care. You have had no significant past medical history to warrant monitored
anesthesia care. There is nothing in the documentation indicating that it was medically necessary to have an
anesthesiologist present during this procedure. Therefore, you do not meet 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 anesthesiology services for a left radiofrequency ablation have not been met.
Therefore, we decided that the Plan does not have to pre-approve anesthesiology services for a left
radiofrequency ablation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional occupational therapy (OT) visits.

You asked the Plan to pre-approve the additional OT visits. You say that you have a rare disease called inclusion body milosides. You need the occupational therapy because that is the only way to treat this disease. The Plan denied your request. The Plan says the enrollee does not meet the criteria for additional occupational therapy services as level of function has remained the same despite all therapy received.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the OT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. There has been staff and patient education on self-care tasks, finger extension splint for increased competence. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. Nursing and caregivers report patient maintains level of function. 

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 OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional occupational therapy (OT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services to be provided by an out-ofnetwork
(OON) provider.

You asked the Plan to pre-approve psychotherapy services. You say that you would like to see a provider that
is in the same clinic your husband goes. The Plan denied your request. The Plan says they have in-network
providers available to meet your medical needs.

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
psychotherapy services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional chiropractic services.

You asked the Plan to pre-approve additional chiropractic services. 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 must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care.

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 additional chiropractic services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has been receiving chiropractic care for 13 months. The provided records do not indicate that there is ongoing improvement as measured by pain scores. The provided records do not indicate a reasonable expectation of continued improvement. The provided services are considered maintenance therapy, which is excluded from coverage. Therefore, the enrollee does not meet 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 additional chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional chiropractic services.