Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted with acute hypoxic respiratory failure due to COVID-19 infection. The record indicates that the enrollee has had a gastrointestinal bleed and urinary tract infection but is gradually improving receiving oxygen via nasal cannula. The record indicates that the enrollee requires acute care services.  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 she is 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found 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. The enrollee was admitted for sepsis and COVID pneumonia.
Medical problems are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.
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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652 and E0667).

You asked the Plan to pre-approve a pneumatic compression device. You say that the member need this item.
The Plan denied your request. The Plan says the member does not meet the criteria for these items.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has
lymphedema extending onto chest/ trunk/ or abdomen and had at least four weeks of regular, daily, multiple-hour
home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician
who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that
the Plan does not have to pre-approve a pneumatic compression device (E0652 and E0667).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.
You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
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 additional PT 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 based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for your condition. Based on the available records, you appear to have improved with therapy to the point of being able to manage functional anterior and above horizontal range of motion; your therapist feels you may not be able to reach behind your back with your right arm due to the nature of your shoulder replacement. Further skilled therapy beyond the 29 approved visits at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. There is no documentation 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 under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration 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 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (J0881).
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not being prescribed for a medically accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Aranesp. Our reviewer says that Aranesp is not medically necessary. Our physician reviewer found the use of Aranesp is not supported by the Food and Drug Administration (FDA) for anemia with inadequate iron stores. The reviewer found that the use of Aranesp for anemia with inadequate iron stores is not supported by the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the reviewer found that the requested drug does not meet Medicare criteria for safe and effective and otherwise reasonable and necessary for this enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Specifically, the file does not indicate that the requested drug is supported by the FDA for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve Aranesp (J0881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bite guard (42899).

You asked the Plan to pre-approve a bite guard. You say that you need this item. The Plan denied your request.
The Plan says the record sent by your provider fails to indicate you have bruxism, obstructive sleep
apnea, or have had jaw surgery.

The Plan must follow Medicare rules. Medicare rules say that all the criteria in the Medicare Rules section of
this letter must be met.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a bite guard have not been met. Therefore, we decided that the Plan does not have to pre-approve a
bite guard (42899).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) physical therapy (PT) evaluations (97162) and 12 physical therapy (PT) visits (97110, 97530, 97140, 97112, 97116, 97010, 97032, 97014) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve PT visits. You say that you need to continue with your PT visits and this provider is close to your residence. The Plan denied your request. The Plan says you must receive care from a network provider.

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. The records provided for review do not show that the services at issue are urgent or emergent. 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 twelve (12) physical therapy (PT) evaluations (97162) and 12 physical therapy (PT) visits (97110, 97530, 97140, 97112, 97116, 97010, 97032, 97014) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services and a flu shot provided out
of network on September 24, 2020.
You asked the Plan to pay for out of network services. You say that these services should be covered by the
Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
We overturned the Plans denial stating the flu shot is covered under Medicare Part B. The Plan requested
a reopen and stated that while the flu shot is a covered benefit, enrollees must still follow the Plan contract
rules when getting care and services. The Plan states you did not have prior authorization for out of network
care.
The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network
providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only
in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out of network physician services and a flu shot
provided out of network on September 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional home health visits.  You asked the Plan to pre-approve the additional home health visits. You say that the additional visits are medically necessary. The Plan denied your request. The Plan says sufficient home visits have already been approved. Additional visits are not medically necessary.  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 additional home health visits. Our reviewer says that the additional home health visits are not medically necessary. Our physician reviewer found the enrollee does not have documented, ongoing, skilled therapy needs. The enrollee appears to be reaching a plateau in function. The enrollee's 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 the additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pilates classes.

You asked the Plan to pre-approve Pilates classes. The Plan denied your request. The Plan says Pilates classes
are not part of the Plan's fitness program.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

The Plan's rules for coverage of gym benefits have not been met because Pilates classes are not part of the
Plan's fitness program. Therefore, we decided that the Plan does not have to pre-approve Pilates
classes.
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 the records provided support the need for SNF care. The Plan denied your request. The Plan says SNF care is not medically necessary for the enrollee at this time.
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 the enrollee has stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The enrollee no longer requires daily skilled nursing and/or skilled therapy services. She could benefit from continued intermittent services at a lower level of care. Although the enrollee made slow progress with therapy, her functional improvement has plateaued, there is no indication that transfer to a skilled nursing facility is required. She can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehabilitation services 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 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 admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says medical issues appear to have been essentially stabilized.
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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level is near baseline and does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the compression socks (E1399).  You asked the Plan to pre-approve the compression socks.. You say that you need this item. The Plan denied your request. The Plan says this would be considered a comfort or convenience item or hygienic equipment that is not primarily medical in nature and therefore is not covered by Medicare.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the compression socks (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM)
and supplies.
You asked the Plan to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) and supplies. You
say that you need this item. The Plan denied your request. The Plan says there is already an approval for a
CGM on file, making this request a duplicate.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have Freestyle Libre 14-day CGM and supplies. This serves the same purpose as a
Freestyle Libre 2 continuous glucose monitor (CGM) and supplies. Therefore, we decided that the Plan does
not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal cord stimulator (SCS) placement.

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 an SCS trial is covered when specific criteria are
met.

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 chronic neck pain. She
had a prior SCS placement for lumbar pain with lead revision. She has not had recent trials of physical therapy
or other conservative therapy. There is no evidence-based indication for the SCS trial. She has not had a
surgical consultation. The criteria for coverage are not met and 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 spinal cord stimulator (SCS) placement.