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

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that you need SNF care.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 Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do 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. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter you do 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe four porcelain retainer crowns and two porcelain pontics provided on June 25, 2019.You asked the Plan to pay forthe retainer crowns and pontics. You say that you say that the enrollee's dentist discovered that her upper front plate was damaged and needed to be replaced. You also say that these services should be covered because it was the direct result of an injury.The Plan denied your request. The Plan says these services are not covered under the enrollee's contract under any normal circumstances. The Plan also says that the enrollee's 2019 EOC has no routine dental coverage.Medicare generally does not cover dental services. The Plan follows the same rule.The servicesyou are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe four porcelain retainer crowns and two porcelain pontics provided on June 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan provided on September 7, 2019.You asked the Plan to pay for the duplex scan. The Plan denied your request.The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider and the referring provider in this case are notnetwork providers with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a duplex scan provided on September 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (G0277).You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that the service is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that coverage of hyperbaric oxygen therapy is limited to certain conditions.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 hyperbaric oxygen therapy. Our reviewer says that the service is not medically necessary. Our physician reviewer found the review has 
determined that the enrollee does not meet the coverage criteria. The requested hyperbaric oxygen therapy is not medically reasonable and 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 hyperbaric oxygen therapy have not been met.Therefore, we decided that the Plan does not have topre-approve hyperbaric oxygen therapy (G0277)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacral nerve stimulation.You asked the Plan to pre-approvesacral nerve stimulation. You say that you successfully completed a 2-day stimulation trial and feel it is the best solution for you.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because sacral nerve stimulation is not covered by Medicare under these conditions.The Plan follows Medicare rules. Medicare rules say that enrollees with specific neurological diseases associated with secondary manifestations of urinary incontinence, frequency, or retention are excluded from coverage at this time.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 sacral nerve stimulation. Our reviewer says that you do not meet the Medicare criteria for the requested sacral nerve stimulation. Our physician reviewer found sacral nerve stimulation is considered investigational for enrollees with multiple sclerosis and bladder dysfunction. Randomized controlled trials are limited in this area; however, this procedure offers great promise to this often-complex patient population. Future studies are warranted and necessary to better evaluate the effectiveness of this treatment option.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacral nerve stimulation have not been met.Therefore, we decided that the Plan does not have to pre-approvesacral nerve stimulation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the records provided support the need for IRF care.The Plan denied your request. The Plan says the Medicare criteria for coverage have not been established. The plan says that the clinical documentation shows that the enrollee is currently functioning at a level that can be managed in an alternate 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 above.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility(SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. The enrollee is mostly minimal assist for functional transfers and activities of daily living and a less intensive, longerduration of therapy can allow for measurable gains to be attained within a predicted period.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic treatment you provided on August 13, 2019.You asked the Plan to pay for the chiropractic treatment.The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for chiropractic treatment you provided on August 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on September 9, 2019.You asked the Plan to pay forthe periodic oral evaluation and prophylaxis. You say that you contacted the Plan and inquired about an in-network dentist in your area. You also say that the customer service representative said she was unable tofind a list of in-network providers in your area and said to have your dentist send a claim.The Plan denied your request. The Plan says this dentist is an out-of-network provider.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 covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on September 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion medications you provided on September 19, 2019 and September 24, 2019.You asked the Plan to pay for the home infusion medications. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan.The Plan did not pre-approve the home infusion medications. We found no exception that would require the Plan to pay for these items.Therefore, we decided that the Plan does not have to pay for home infusion medications you provided on September 19, 2019 and September 24, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99202) and thex-ray exam of the cervical spine (72050) provided on July 9, 2019.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denialas you originally obtained a referral for the services.The Plan denied your request. The Plan says these services are not a covered benefit under Medicare or your health plan policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the servicesat issue arenot manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe office visit (99202) and the x-ray exam of the cervical spine (72050) provided on July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe leg prosthesis with advanced knee, foot and ankle feature to be provided. You asked the Plan to pre-approvethe prosthesis. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says this request does not meet Medicare criteria as reasonable and necessary.The Plan must follow Medicare rules. Medicare rules say that items and services thatare 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 prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not show that K3 components are medically required. There is no documentation by the physician ofwhy the enrollee needs K3 component where otherwise a more stable K2 component would meet and not exceed the enrollee's ambulation needs to maintain independent living in the home and complete basic community ambulation tasks.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 prosthesis have not been met.Therefore, we decided that the Plan does not have to pre-approvethe leg prosthesis with advanced knee,foot and ankle feature to be provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 31, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent oremergency situation, has been documented.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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case and the ordering provider are not network providers with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on July 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH care.The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.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 ventilator dependent with a tracheostomy prior to admission. She is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The documentation does not support that the enrollee is expected to require greater than 25 days of additional hospitalization. There are no required medical services identified thatare available at the LTACH, which are not available at the current health care setting being offered by the health plan.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-approvelong term acute care hospital (LTACH) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from June 12, 2019 to August 31, 2019.You asked the Plan to pay forthe diabetic supplies. The Plan denied your request. The Plan says that there is no valid proof of delivery.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the itemsat issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered.Therefore, we decided that the Plan does not have to pay forthe diabetic supplies provided to the enrollee from June 12, 2019 to August 31, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies coded as A4253, A4259, A4256 and A4235 provided August 9, 2019 to October 28, 2019.You asked the Plan to pay for the diabetic supplies. You say that the medical records provided support the necessity of the services in disputeThe Plan denied your request. The Plan says there was no evidence of an established relationship between the enrollee and the ordering physician, no evidence of a prior telehealth service with the ordering physician and there were no claims submitted for an evaluation and management service.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following thenon-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay forthe diabetic supplies coded 
as A4253, A4259, A4256 and A4235 provided August 9, 2019 to October 28, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BAHA cochlear implant.
You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your
request. The Plan says based on the documentation provided, 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 the implant. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee does not meet FDA approved indications for the BAHA device. The BAHA is an effective
hearing solution for people with conductive or mixed hearing loss or single-sided sensorineural deafness. The
BAHA is intended for patients with a mixed hearing loss who can still benefit from sound amplification. The
PTA bone-conduction hearing threshold should be better than or equal to 65dB HL. The enrollee's PTA for
bone-conduction hearing threshold is 70dB. Therefore he does not meet criteria.
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 implant have not been met. Therefore, we decided that the Plan does not
have to pre-approve BAHA cochlear implant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre continuous glucose monitoring with supplies.You asked the Plan to pre-approve continuous glucose monitoring with supplies. You say that that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan saysthe records do not show that the Medicare requirements have been met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.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 continuous glucose monitoring with supplies. Our reviewer says that this enrollee does not meet the criteria. Our physician reviewer found the enrollee is not taking multiple shots of insulin per day and is not using insulin which is adjusted day by day according to BG level at a given time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitoring with supplies have not been met.Therefore, we decided that the Plan does not have to pre-approveFreeStyle Libre continuous glucose monitoring with supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.You asked the Planto pre-approve the out-of-network services. You say that the enrollee is in bad shape.The Plan denied your request. The Plan says the service requested is available in network.Medicare rules say that plans can require enrollees to get care fromnetwork 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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider.