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

We decided that the Plan does not have to pre-approve continuation of inpatient psychiatric care from
December 13, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that ongoing inpatient care is
medically necessary for this enrollee, who has nowhere to go because he is homeless. Ongoing care is
necessary to manage his health conditions and depression. The Plan denied your request. The Plan says as of
December 13, 2021, the enrollee does not meet the criteria for ongoing inpatient psychiatric services and can be
treated in a less restrictive setting.
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 psychiatric care.
Our reviewer says that the Plan's denial of continued psychiatric care at the inpatient level appears appropriate
in this case. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric
hospitalization on December 2, 2021, with Major Depressive Disorder, Recurrent, Severe without Psychotic
Features. Based upon review the records provided it was not expected this enrollee would improve in a
reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or
others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats
of safety. The enrollee was cooperative and compliant with medication. It did not appear medically necessary
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of
care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual
hallucinations or abnormal behaviors. It did not appear that active treatment was taking place beyond the date
in question. It did not appear that the services for the dates in question were reasonably expected or medically
necessary to improve the enrollee's condition or for the purpose of diagnosis. Based upon review the records
provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment
beyond the date in question of December 13, 2021, forward, and could have been treated in a lesser restrictive
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 continued inpatient psychiatric care have not been met. Therefore, we decided
that the Plan does not have to pre-approve continuation of inpatient psychiatric care from December 13, 2021,
forward
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that you need this item because your knees and
back hurt. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
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 power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual wellness visit (G0439) provided July 27, 2021.
You asked the Plan to pay for the annual wellness visit. You say that the services were medically necessary.
The Plan denied your request. The Plan says the benefit for this service was exhausted at the time the service
was rendered.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once
every 12 months.
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case.
Therefore, we decided that the Plan does not have to pay for an annual wellness visit (G0439) provided July 27,
2021.
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 transfer to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can be treated safely and effectively in a less intensive level of care.
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. 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 this 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 replacement power wheelchair (K0856) and
accessories.
You asked the Plan to pre-approve a replacement power wheelchair and accessories. You say that this
enrollee's change in condition warrants a replacement power wheelchair. The Plan denied your request. The
Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that the reasonable usefulness of an item in no cases is
less than 5 years. Repair is covered up to the cost of the replacement.
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 replacement power wheelchair and
accessories. Our reviewer says that the requested power wheelchair and related accessories are not medically
reasonable and necessary. Our physician reviewer found based on the medical records provided there is no
documentation that the enrollee's current power wheelchair which is less than 5 years old cannot be repaired
and modified to meet the enrollee's mobility needs.
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 replacement power wheelchair and accessories have not been met. Therefore,
we decided that the Plan does not have to pre-approve a replacement power wheelchair (K0856) and
accessories.
Appeal type: Testing
Decision: Unfavorable

You asked the Plan to pre-approve a wireless capsule endoscopy. You say that the enrollee is a poor candidate
for sedation with an upper endoscopy and colonoscopy. The Plan denied your request. The Plan says the
enrollee does not meet criteria for coverage of a wireless capsule endoscopy.
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 wireless capsule endoscopy. Our
reviewer says that the requested wireless capsule endoscopy is not considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee has neither undergone upper endoscopy nor
colonoscopy, and in fact declines same without documentation of absolute contraindication to the procedures or
sedation. Available records provide neither pertinent laboratory results nor radiographic abdominal imaging.
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 wireless capsule endoscopy have not been met. Therefore, we decided that the
Plan does not have to pre-approve a wireless capsule endoscopy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.
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 Vertiflex procedure. 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. More research is needed to show 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 the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110).
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that the service at issue is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the services
requested.
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 wireless capsule endoscopy. Our
reviewer says that the requested a wireless capsule endoscopy is not considered medically reasonable and
necessary in this case. Our physician reviewer found the available records support no radiographic evidence of
small bowel pathology and no detection of occult or visible gastrointestinal bleeding to warrant the services
requested as 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 a wireless capsule endoscopy have not been met. Therefore, we decided that the
Plan does not have to pre-approve a wireless capsule endoscopy (91110).
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 stay is medically necessary. 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 with hypoxic respiratory failure due to Coronavirus
pneumonia. The record indicates that the enrollee continues to require acute care services including high flow
oxygen and is not clinically stable. 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: 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 complex wound care, new enteral feedings, or other skilled nursing SNF need. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmologist services to be provided by an out-
of-network provider.
You asked the Plan to pre-approve the out-of-network ophthalmologist services. You say that you are
requesting review of denial of services. The Plan denied your request. The Plan says there are in-network
providers in the enrollee's service area that can provide this service.
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
the ophthalmologist services to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy to be performed at a hospital instead of
an ambulatory surgery center (ASC).
You asked the Plan to pre-approve a colonoscopy to be performed at a hospital instead of an ASC. The Plan
denied your request. The Plan says based on the clinical documentation, the enrollee is low-risk, and the
colonoscopy can safely be performed in an ASC setting.
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 colonoscopy to be performed at a
hospital instead of an ASC. Our reviewer says that a colonoscopy to be performed at a hospital instead of an
ASC is not considered medically reasonable and necessary in this case. Our physician reviewer found the
records provided do not support that the enrollee meets the Plan's policy, nor the medical appropriateness and
necessity for an in-hospital colonoscopy.
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 colonoscopy to be performed at a
hospital instead of an ASC have not been met. Therefore, we decided that the Plan does not have to pre-
approve a colonoscopy to be performed at a hospital instead of an ASC
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve office visits. You say that you have been seeing the requested provider for many years. The Plan denied your request. The Plan says these services are available in-network.
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 office visits 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 stair lift.
You asked the Plan to pre-approve the stair lift. You say that the item is medically necessary for the enrollee. The Plan denied your request. The Plan says stairway elevators such as stair lifts are specifically excluded from coverage as they are considered convenience items and are not primarily medical in nature.
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 a stair lift
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has a past medical history of stroke wit hemiparesis in 2002. The patient is living at home with progressive difficulty with daily function. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq for the enrollee.
You asked the Plan to pre-approve Tecentriq. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that medical studies haven't proven that Tecentriq is helpful when you've already tried a similar drug (anti-PD-1 therapy) and didn't have a positive response.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Tecentriq. Our reviewer says that Tecentriq is not medically reasonable and necessary for the enrollee. Tecentriq is not FDA-approved for the enrollee's diagnosis. The use of Tecentriq is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Tecentriq.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq for the enrollee.