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

We decided that the Plan does not have to pre-approve an external urine collection system.

You asked the Plan to pre-approve the external urine collection system. You say that this item is medically necessary. The Plan denied your request. The Plan says the type of item requested is a disposable incontinence item and is not covered.

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 an external urine collection system.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vasopneumatic therapy, neuromuscular re-education and electrical stimulation treatment.

You asked the Plan to pre-approve vasopneumatic therapy, neuromuscular re-education and electrical stimulation treatment. 

The Plan denied your request. The Plan says based on Medicare guidelines; the NeoGen Series inferential therapy (transcutaneous electric cell signaling) your provider is requesting to be provided as therapy within the office setting does not meet the requirements for approval. The enrollee has chronic pain due to peripheral neuropathy. There is no evidence the enrollee is being treated for low back pain or is enrolled in a clinical trial for TENS use for low back pain.

The Plan follows Medicare rules. Medicare rules say that Electrical nerve stimulation treatments furnished by a physician in his/her office, by a physical therapist or outpatient clinic are excluded from coverage by 1862(a)(1) of the Act. 

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 vasopneumatic therapy, neuromuscular re-education and electrical stimulation treatment. Our reviewer says that requested vasopneumatic therapy, neuromuscular re-education and electrical stimulation treatment is not medically necessary. Our physician reviewer found that while Medicare does support the use of TENS in chronic intractable pain on a trial basis, the request in this case is for a proprietary combination type of therapy. This therapy involves the use of NMES, vasopneumatic therapy and "neuromuscular re-education" in combination. The NCD is otherwise silent on this combination of treatments. While the FDA has given 510(k) clearance to the requested combination of services, there is a lack of evidence from well-designed clinical trials available to otherwise readily support the proposed treatment in clinical practice. The proposed treatment is not readily consistent with the generally accepted standards of practice or care. Nor is it well supported within current peer reviewed literature. In as much this would not meet Medicare criteria for coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vasopneumatic therapy, neuromuscular re-education and electrical stimulation treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve vasopneumatic therapy, neuromuscular re-education and electrical stimulation treatment.
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 enrollee needs surgery soon and his best chance to be at an optimal level is the IRF. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does
not require an acute inpatient hospital stay with an interdisciplinary approach to rehabilitation care. The
enrollee does require physical and/or occupational therapy, but the enrollee does not require an intensive
rehabilitation therapy 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. Care at the
skilled nursing facility level appears appropriate for the 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 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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that your fingers are getting numb from finger-stick testing. The Plan denied your request. The Plan says the criteria for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three or more times per day.
Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 10-Day Sensor Kit.
You asked the Plan to pre-approve the sensor. You say that you need the Libre senor because you are
diagnosed as being blind. You state a regular glucometer does not work for you and you cannot see to collect
the blood. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation does not show that you are being insulin-treated
with multiple daily insulin administrations and requires frequent changes to your insulin dosing. Based on this
information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we
decided that the Plan does not have to pre-approve Freestyle Libre 10-Day Sensor Kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism placed over or on top of toilet (E0172)

You asked the Plan to pre-approve a raised toilet seat. You say that you need more assistance for daily toileting because of the problems with your inability to sit-t-o stand or stand-to-sit without some kind of powered lift. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. 

While a raised toilet seat may be appropriate for B. Bates-Stokes, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism placed over or on top of toilet (E0172)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).

You asked the Plan to pre-approve Vertiflex. You say that this procedure is recommended as a safer alternative to laminectomy or spinal fusion. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is insufficient evidence of the efficacy of Vertiflex.

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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental/investigational. More research is needed to show its safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care.

You asked the Plan to pre-approve continuation of SNF care. You say that SNF care continues to be medically
necessary for your condition. The Plan denied your request. The Plan says the criteria for SNF care is no longer
met.

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 continuation of SNF care. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled
nursing service needs and no identifiable skilled therapy service needs. In addition, you do not require skilled
nursing or therapy services on a daily basis. In conclusion, you do 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 continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve these services. You say that it is difficult for you to lift the enrollee. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion surgery.

You asked the Plan to pre-approve SI joint fusion surgery. You say that this is medically necessary to resolve
the enrollee's SI joint pain. The Plan denied your request. The Plan says the denial of authorization for this
service is correct, because this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SI joint fusion surgery. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee did not get better with SI joint ablation and has a prior lumbar fusion
with degenerative changes. It is not clear that SI joint pain is present.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SI joint fusion surgery have not been met. Therefore, we decided that the Plan
does not have to pre-approve sacroiliac (SI) joint fusion surgery.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the IRF services provided on April 19, 2020, through April 23, 2021.

You asked the Plan to pay for the IRF services. You say that you would like reconsideration because the Plan's
physician recommended IRF care as it was medically necessary. The Plan denied your request. The Plan says
that the member's care could have been rendered at a lower level of service.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.

The enrollee was referred for the IRF services by a contract provider. The file does not show that the plan
provided notice that the IRF services would not be covered. Under Medicare rules, this means the IRF services
is considered approved by the plan. Therefore, we decided that the Plan has to pay for the IRF services
provided on April 19, 2020, through April 23, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluid Flow/Fluid GF injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the efficacy of this injection has not been established.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence for stem cell injections in the setting of bilateral plantar nerve enthesopathy is still limited and lacking in higher quality long-term standardized trials as of yet. A review of the current medical literature indicates that this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language. The review has determined that the requested service is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Fluid Flow/Fluid GF injection for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services from December 14, 2021 and forward.
You asked the Plan to pre-approve continued inpatient mental health services from December 14, 2021 and forward. You say that the requested continued inpatient mental health services from December 14, 2021 and forward are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued inpatient mental health services from December 14, 2021 and forward.
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 continued inpatient mental health services from December 14, 2021 and forward. Our reviewer says that the enrollee does not meet criteria for continued inpatient mental health services from December 14, 2021 and forward. Our physician reviewer found 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, no auditory hallucinations 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 it is alluded to in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review of the records provided, the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of December 14, 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. This enrollee was not showing any aggressive behaviors, or any treatment required for acute threats of 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 continued inpatient mental health services from December 14, 2021 and forward have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health services from December 14, 2021 and forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex Superion Interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not state that the enrollee is not indicated for operative intervention at no more than two levels. The elements of the coverage criteria 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 a Vertiflex Superion Interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception for in-network coverage for outpatient
dialysis services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an exception for in-network coverage for outpatient dialysis services to be
provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan
says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not
been met.
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 an exception for in-network coverage for outpatient dialysis services to be provided by an out-of-network (OON) provider.