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

We decided that the Plan does not have to pay for the self-administered drugs provided From October 26, 2020, to November 4, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you want this admission to be inpatient because you were in a room for eight days. You also say that you do not believe the outpatient charges are justified because Medicare limits outpatient care to 48 hours. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided From October 26, 2020, to November 4, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care.
You asked the Plan to pre-approve inpatient psychiatric care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 inpatient psychiatric care. Our reviewer says that the service is not medically necessary. Our physician reviewer found it is not expected you would
improve in a reasonable period of time as you do not have suicidal or homicidal ideation noted and you denied any auditory or visual hallucinations. You are not a danger to yourself or others, and therefore, do not require inpatient psychiatric 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 inpatient psychiatric care have not been met. Specifically, you are not a danger to yourself or others, and therefore, do not require inpatient psychiatric care. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that this item is necessary. The Plan denied your request. The Plan says a shower seat is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair. The subsequent home revisions for this statutorily non-covered item will also be not covered.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat bilateral facet joint injections.

You asked the Plan to pre-approve repeat bilateral facet joint injections. You say that this request is medically necesary. 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 there must be pain relief of 80% from the prior injection before a repeat injection will be approved. 

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 repeat bilateral facet joint injections. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found the patient did not receive significant pain relief from the prior intervention. Therefore, the criteria of the LCD are not met. The request is considered not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of repeat bilateral facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat bilateral facet joint injections.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve RFA. You say that the services are necessary. The Plan denied your request.
The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one
providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief
being consistent with the agent used).
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 RFA. Our reviewer says that the
services are medically necessary. Our physician reviewer found even though you should not have had the
initial RFA approved since you had less than 50% pain relief from the diagnostic blocks, since it has in fact
provided pain relief as specified in the LCD, the request is 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 RFA have been met. Therefore, we decided that the Plan has to pre-approve
radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of tooth #5 to existing partial denture and to pay more for the addition of tooth #11 to existing partial denture provided on January 4, 2021 by an OON provider.
You asked the Plan to pay for the tooth additions. You say that you should get 45% off of the charge for each tooth addition because you did not have the information. The Plan denied your request. The Plan says the tooth additions were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that your benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, denture adjustments are limited to one procedure code per calendar year, you are responsible for a 75% coinsurance for denture adjustments that are received OON. The record shows that you received two tooth additions on January 4, 2021, one of which was covered at the OON rate of 25% by the Plan, and your denture adjustment benefit has been exhausted. The record also shows that you contacted the Plan on November 23, 2020, and only your benefits for extractions and full dentures were reviewed, you did not request any other benefits during this call. Therefore, we decided that the Plan does not have to pay for the addition of tooth #5 to existing partial denture and to pay more for the addition of tooth #11 to existing partial denture provided on January 4, 2021 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that the requested power wheelchair is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested power wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power wheelchair. Our reviewer says that the enrollee does not meet criteria for the requested power wheelchair. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets all of the Local Coverage Determination (LCD): Power Mobility Devices (L33789) criteria for the requested power wheelchair. There is no documentation that the enrollee's mobility deficit cannot be helped by the use of a walker or manual
wheelchair, records indicate the enrollee uses a walker and manual wheelchair in the Mainplace Post Acute facility. Based on the medical records provided there is no documentation that the enrollee can safely operate a power mobility 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 a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that skilled nursing facility admission is medically necessary for this enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The medical records do not show that the enrollee requires skilled nursing or therapy services daily. The enrollee does 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit (Q5106).
You asked the Plan to pre-approve Retacrit. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that ESA agents will not be covered for certain clinical conditions including any anemia in cancer or cancer treatment patients due to folate deficiency, B-12 deficiency, iron deficiency, hemolysis, bleeding, or bone marrow fibrosis. 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 Retacrit. Our reviewer says that the requested drug is not medically reasonable in this case. Our physician reviewer found the enrollee is a 68-year-old woman who has been diagnosed with pancreatic adenocarcinoma. The enrollee is receiving chemotherapy and has a hemoglobin of 7.5 g/dl. The record indicates that the enrollee has a low iron and iron saturation level with elevated erythropoetin level. The elements of the coverage rule are not satisfied because the enrollee has an exclusionary indication. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit (Q5106).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313) and electronic connection (E2311) for use with a power wheelchair for the enrollee.
You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313) and electronic connection (E2311). You say that the requested accessories are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these accessories for the enrollee. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found based on the medical records provided there is no documentation that the expandable controller (E2377), expandable controller harness (E2313) and electronic connection (E2311) at issue in this case meet Medicare criteria for medical necessity.
The medical records document that the enrollee has three out of five scale upper extremity strength and is independent with feeding indicating adequate upper extremity strength and function to operate the power options with their own switches. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage these accessories are not met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313) and electronic connection (E2311) for use with a power wheelchair for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for
continued SNF care.
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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is consistently ambulating more than 100 feet and tending to activities of daily living 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 at this point 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cologuard testing (81528).
You asked the Plan to pre-approve Cologuard testing. You say that this should be covered because you have had a traumatic experience with a colonoscopy. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered once every three years for Medicare beneficiaries that are between age 50 and 85 years old. We looked at the file and Medicare rules. The record shows that you are 91 years old. Based on this information, we decided that Medicare rules for coverage of Cologuard testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Cologuard testing (81528).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitoring system.
You asked the Plan to provide a therapeutic continuous glucose monitoring system. You say that the enrollee needs a therapeutic continuous glucose monitor. The Plan denied your request. The Plan says the documentation indicates that the enrollee has been testing glucose 2-3 times a day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitoring system have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitoring system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI of the lumbar spine. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon the totality of the record, an MRI is not medically reasonable or necessary, as defined by Medicare rules, at this time. The elements of the coverage criteria are not satisfied. The requested service is not recommended at this 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 an MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ketamine.

You asked the Plan to pre-approve Ketamine. You say that this is medically necessary. The Plan denied your request. The Plan says the requested use of this drug is not supported.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Ketamine. Our reviewer says that the use of Ketamine is not supported in this case. Our physician reviewer found Ketamine is not FDA approved for the management of migraine headaches. This use is also not supported by the major drug compendia, authoritative medical literature, or accepted standards of medical practice. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ketamine have not been met. Therefore, we decided that the Plan does not have to pre-approve Ketamine.
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 you still have left-sided weakness. The Plan denied your request. The Plan says you do not require an intensive therapy program with multiple visits from a rehab doctor.
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 physician reviewer found that you were admitted to the acute hospital for left-sided weakness, a urinary tract infection, and an ankle fracture for which no surgery was recommended. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of SNF care. You say that the enrollee continues to require SNF care beyond the 100-day benefit limit. The Plan denied your request. The Plan says the benefit for SNF care has been exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from January 11, 2021, to June 22, 2021. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.