Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network oncology services.
You asked the Plan to pre-approve out-of-network oncology services. You say that the requested out-of-network oncology provider is medically necessary. The Plan denied your request. The Plan says the requested out-of-network oncology provider is not medically necessary.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for 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 out-of-network oncology services. Our reviewer says that the requested out-of-network oncology provider is not medically necessary. Our physician reviewer found in this case, the record indicates that the enrollee has a diagnosis of lung adenocarcinoma, status post video-assisted thoracoscopic surgery (VATS). The record indicates that the plan has in network providers that are available to provide the required services. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 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 out-of-network oncology services have not been met. Therefore, we decided that the Plan does not have to pre-approve out-of-network oncology 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 require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. Care in the home with home health services and caregivers or at the skilled nursing facility level appears to be appropriate in this case. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 19.
You asked the Plan to pre-approve the crown. You say that you recommend a removal of the defective crown
and replacement with a new crown with adequate margins. The Plan denied your request. The Plan says this
service is not medically necessary. The Plan also says that the enrollee's tooth does not have 50% bone support.
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. The Plan covers the crown
when the services are medically necessary and reasonable.
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 crown. Our reviewer says that given
the presentation of tooth #19, and its poorer long-term prognosis due to the furcation involvement, it would not
meet the Plan criteria for a new crown. Our physician reviewer found the tooth exhibits bone loss between the
mesial and distal roots as well as approximately 50% loss on the distal aspect of the tooth. The loss of bone
between the roots is called a furcation involvement and leads to a much lower long-term prognosis for that
tooth due to progressive loss of bone in that area. Our reviewer also found that the Plan specifically does not
cover crowns in those situations where furcation involvements are present.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have
to pre-approve a crown (D2740) for tooth # 19.
Appeal type: Inpatient Hospital
Decision: Unfavorable

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 based on the documentation
provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The
enrollee's care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
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 based on the documentation
provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.
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 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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The
enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee has failed conservative treatment and a simpler pump would be ineffective in treating his condition. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee has not completed a 4-week trial of appropriate conservative therapy.
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 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).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
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 admission to a SNF. Our reviewer says
that daily skilled services are not 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 new enteral feedings, or other skilled nursing SNF need. The enrollee's ischial stage 3
wound is chronic and was present and being treated prior to admission. The enrollee's functional level 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 admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed and a general use wheelchair back cushion.
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not require frequent changes in positions to make a semi-electric feature needed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 items. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that you require frequent changes in body position or immediate changes in body position. There is no documentation that your condition requires special attachments that cannot be fixed and used on an ordinary bed. You would meet criteria for a standard hospital bed, but you do not meet the criteria for a semi-electric hospital bed. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed and a general use wheelchair back cushion.
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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is
not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 home health physical therapy visits.
You asked the Plan to pre-approve 6 home health physical therapy visits. 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. 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 6 home health physical therapy visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent 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 6 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 home health physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the IRF admission covered. The Plan denied your request. The Plan says your request for approval of an IRF admission does 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual transport wheelchair (E1038).
You asked the Plan to pre-approve the wheelchair. You say that the wheelchair is medically necessary. The Plan denied your request. The Plan says the provided records show that this wheelchair is for use outside the home, and it is therefore non-covered.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a manual transport wheelchair (E1038).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Fluid Flow/Fluid GF injection.
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 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. Based on Medicare guidelines, the Fluid Flow (Q4206) is amniotic liquid allografts derived from human amniotic tissue (stem cells). The enrollee's condition doesn't meet the rules for approval because you do not have any approved indication for stem cell therapy (amniotic cell therapy). he request is not medically reasonable and necessary under Medicare guidelines.
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 a Fluid Flow/Fluid GF injection
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet injections (64493, 64494, 64495).
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied
your request. The Plan says the requested injections conflict with the documentation.
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 injections. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that the review has determined that the enrollee does not have a covered indication for the
requested bilateral lumbar medial branch blocks as requested.
We looked at this physician's review, the file, and Medicare rules. There is no evidence of any unique
circumstances to consider a three-level procedure. Based on this information, we decided that Medicare rules
for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to preapprove
lumbar facet injections (64493, 64494, 64495