Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care
after November 10, 2021.
You asked the Plan to pre-approve the continuation of SNF care. You say that you continue to require SNF
care. The Plan denied your request. The Plan says SNF care is no longer medically reasonable and necessary.
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 continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 77-year-old
male with schizoaffective disorder and coronavirus infection. In this case, there are no identifiable skilled
therapy service needs and no identifiable skilled nursing 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 the continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after November 10,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required
(D2950).
You asked the Plan to pre-approve the core buildup. You say that this service is necessary to hold the crown
on. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that
includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water
and/or phone bill payments (debit card), home assistance services (repairs).
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes
transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or
phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan
says that the certification dated September 27, 2021, documented that the enrollee has none of the qualifying
diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for
adverse health outcomes.
The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you
must have one or more comorbid and medically complex chronic conditions that are life-threatening or
significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization
or other adverse health outcomes; and must require intensive care coordination.
We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical
conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to preapprove
special supplemental benefits for the chronically ill that includes transportation for non-medical needs,
an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home
assistance services (repairs).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64635, 64636).
You asked the Plan to pre-approve a radiofrequency ablation. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that, for each covered spinal region, no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a radiofrequency ablation have not been met. Specifically, the enrollee has had two prior sessions of radiofrequency ablation within the past 12 months. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64635, 64636).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says this procedure is investigational and non-covered. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested Vertiflex device is experimental. More research is needed to show 
safety and efficacy of the device. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from June 3, 2020, to June 15, 
2020. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the billed 
diagnosis code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with N17.0. 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 pay for the inpatient care. Our reviewer says that the use of diagnosis code N17.0 is not 
supported by the records provided. Our physician reviewer found that the documentation was 
inconsistent/unclear regarding a diagnosis of acute tubular necrosis (ATN). Even though ATN is documented 
on progress notes and discharge summary, supporting medical record documentation was not found within the 
record. While the enrollee's presentation warranted consideration of acute kidney failure with tubular necrosis 
as a possible diagnosis, there was no evidence of urinalysis with non-hyaline casts (granular or muddy casts or 
renal tubular cells), Urinary sodium > 40 mEq/L, FeNA > 2%, or Renal biopsy confirmation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient care provided from June 3, 2020, to June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1852).
You asked the Plan to pre-approve a knee orthosis. You say that this requested item is medically reasonable and necessary. The Plan denied your request. The Plan says the Medicare coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis is subject to the criteria listed 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 a knee orthosis. Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 57-year-old female with right knee pain related to osteoarthritis. Based on the medical records provided there is no documentation that the enrollee meets the coverage criteria detailed in the Local Coverage Determination (LCD): Knee Orthoses (L33318) for the requested knee orthosis (L1852). Records do not document knee instability on examination or objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). 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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1852).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not had an osteoporosis related fracture and has not tried and failed zoledronic acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our physician reviewer found that the enrollee has a history of osteoporosis. The Plan requires a trial of zoledronic acid or an osteoporosis-related fracture before they will approve the requested drug. In this case, the enrollee has not met the criteria. There is no documentation provided indicating that the Plan's requirements would likely be less effective or likely have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
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 weakness, dementia and agitation. 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 documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system.
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF system 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 a CardioMEMS HF system. Our reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer found the record indicates that the enrollee has class III NYHA heart failure and has been hospitalized recently for heart failure exacerbation. The enrollee's body mass index is 50.94. The record does not indicate the enrollee's chest circumference. 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 a CardioMEMS HF system have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) services performed by a qualified physical
therapist in the home health (HH) or hospice setting, each 15 minutes (CPT code G0151 X 4), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the enrollee can walk safely, improve their balance, and teach the enrollee and their
caregiver a home exercise program. The Plan states the enrollee's records suggest that continuing this exercise
program should help the enrollee maintain their level of function or improve further. The Plan states the
enrollee's records do not support the need for a skilled physical therapist to make more home visits at this time.
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 services. Our physician reviewer
found the health plan's denial should be upheld. The enrollee does not have documented skilled home physical
therapy (PT) needs. The enrollee is functioning at a level commiserate with a lower level of care (i.e., HEP,
outpatient therapy). As such, the requested, ongoing, HH PT is not medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve four (4) services performed by a qualified physical therapist in the home health (HH) or
hospice setting, each 15 minutes (CPT code G0151 X 4), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator.
You asked the Plan to pre-approve an auricular peripheral nerve stimulator. You say that this requested device is medically necessary. The Plan denied your request. The Plan says this service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that auricular peripheral nerve stimulation will be denied as noncovered. This service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary. on this information, we decided that Medicare rules for coverage of an auricular peripheral nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator.
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 the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee's condition does not meet the criteria for coverage of SNF care. The Plan says that the enrollee's needs are custodial in nature.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating household distances and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device (L8702).
You asked the Plan to pre-approve MyoPro Motion G Orthotic device. You say that the requested item is
medically necessary. The Plan denied your request. The Plan says the requested device currently
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 MyoPro Motion G Orthotic device. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found based on the medical records provided there is no documentation that the
enrollee meets Medicare criteria for coverage of the MyoPro Motion G Orthotic device. Current clinical
guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper
limb exercise therapies" with unproven benefit in the home environment. In addition, no records from a treating
provider who has examined the enrollee recommend the device. Also, records indicate the enrollee has a
shoulder subluxation which can be a contraindication to use of the device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of MyoPro Motion G Orthotic device have not been met. Therefore, we decided
that the Plan does not have to pre-approve MyoPro Motion G Orthotic device (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.
You asked the Plan to pre-approve an inpatient hospital admission. You say that the enrollee has high pain
levels. The Plan denied your request. The Plan says the procedure is approved as an ambulatory procedure. The
Plan says that there is no documentation provided to support the expectation that the enrollee will require a
greater than 2 midnight stay. The Plan says that if the enrollee experiences any peri- or post-operative
complications, reconsideration for inpatient level of care can be performed on concurrent review with updated
clinical information.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 an inpatient hospital admission. Our
reviewer says that the documentation does not support that the criteria for an inpatient hospital admission are
met in this case. Our physician reviewer found the record does not document that the treating physician has a
reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for
observation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an inpatient hospital admission have not been met. Therefore, we decided that
the Plan does not have to pre-approve an inpatient hospital admission.
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 you do not require an intensive, complex, multidisciplinary approach to daily
therapy. While you may benefit from physical therapy and occupational therapy, your rehab needs can be
safely met in an alternate and low intensity setting such as a skilled nursing 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 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.