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

We decided that the Plan does not have to pre-approve continued psychotherapy services to be provided by an
out of network (OON) provider.

You asked the Plan to pre-approve the OON psychotherapy services. You say that you have been able to build
trust with this provider for over four years. You feel that it would be harmful to your mental state to have to
restart with a new provider. The Plan denied your request. The Plan says your plan restricts coverage to only
network providers. As there are network psychotherapists available who can treat your condition, there is no
medical need for OON care.

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 provider at issue in this case is not a network provider with the Plan. 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 OON psychotherapy services. Our reviewer says that the documentation
does not support the medical necessity of continuing with the OON therapist. Our physician reviewer found the
enrollee is suffering from depression and post-traumatic stress disorder. Based on review the records provided,
it is noted that this patient would like treatment with her current therapist/physician whom she has seen for the
past 4 years. This patient is not exhibiting any crisis or emergent condition. The medical plan has stated that the
only reason for seeing an out of network provider is in urgent/emergent condition or if a therapist is not
available in network. Based on review the records provided, it does not appear that this patient requires
treatment by an out-of-network provider as the medical plan is able to provide an in network psychotherapist
for the treatment of this patient's condition. This patient does not meet the condition of being in an
urgent/emergent condition. This patient can safely be transitioned to an in network therapist who is
credentialed and certified by her medical 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 OON psychotherapy services have not been met. 

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 the OON psychotherapy services. Therefore, we decided that the Plan does not have to pre-approve continued psychotherapy services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for an empyema. His 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Additionally, 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percutaneous implantation of neurostimulator electrode array, epidural (63650) for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not have screening by a multidisciplinary team to include psychologic clearance for the procedure.

The Plan follows Medicare rules. Medicare rules say that dorsal column stimulators are covered if the above criteria have been met.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. There is no psychological evaluation of the patient submitted and the patient does not have an evidence-based indication for a spinal cord stimulator trial. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous implantation of neurostimulator electrode array, epidural (63650) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre Reader.

You asked the Plan to pre-approve Freestyle Libre Reader. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item.

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 you do not 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. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre Reader have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre Reader.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy.

You asked the Plan to pre-approve medical nutrition therapy services. You say that you would like reconsideration because the services of a nutritionist are helping you to keep your condition under control along with your treatment. The Plan denied your request. The Plan says the obtained documentation does not indicate a diagnosis of diabetes or kidney disease, which are Medicare covered indications for Medical Nutrition Therapy.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. 

Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out-of-network
provider.

You asked the Plan to pre-approve the physical therapy visits. You say that you are in pain and you need to go
to therapy. The Plan denied your request. The Plan says there are in-network providers who can provide the
requested services.

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
physical therapy visits to be provided by an out-of-network provider.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.

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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lower extremity
weakness. The enrollee's 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 medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different level of care. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria
for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve reconstruction of mandible or maxilla, endosteal
implant (e.g., blade, cylinder); complete (CPT code 21249), for the enrollee.

You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied
your request. The Plan says primary dental services in connection with the care, treatment, filling, removal, or
replacement of teeth, or structures directly supporting the teeth are not covered by Medicare.

Medicare generally does not cover dental services. The Plan follows the same rule. The enrollee needs this
procedure for replacement of missing teeth. Therefore, the dental procedures are correct. This enrollee does not
have a supplemental benefit for these specific dental services. Therefore, the denial is correct. The services you
are asking the Plan to pre-approve 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 pre-approve reconstruction of
mandible or maxilla, endosteal implant (e.g., blade, cylinder); complete (CPT code 21249), for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the sleep study, unattended, simultaneous recording of,
heart rate, oxygen saturation, respiratory airflow and respiratory effort (95806).

You asked the Plan to pre-approve the sleep study. You say that your husband was approved for a home sleep
study on 11/11/20 but wasn't able to make the appointment. You were not aware of the required necessity to
pick up the equipment when the appointment was made. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria and the service 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 sleep study. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the reviewed documentation does not indicate the enrollee has gasping or choking at night, disruptive snoring, disturbed, restless, non-restorative sleep and fatigue or excessive daytime sleepiness. The medical records provided do not meet the requirements for Medicare coverage. 

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 sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve the sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow and respiratory effort (95806).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper gastrointestinal endoscopy (43235).

You asked the Plan to pre-approve upper gastrointestinal endoscopy. You say that you have been having stomach problems, cramps and diarrhea. You family has a history of stomach cancer and your doctor feels like this is a necessary procedure. The Plan denied your request. The Plan says the information received show this service 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 upper gastrointestinal endoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available records do not support that the enrollee meets the Medicare criteria listed in the LCD.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of upper gastrointestinal endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve upper gastrointestinal endoscopy (43235).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal implants (D6010) for the upper arch.

You asked the Plan to pre-approve the endosteal implants. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says dental implants for the upper arch are 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. Dental implants are only covered to support the lower full denture. Endosteal implants for the upper arch are not covered. Therefore, we decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal implants (D6010) for the upper arch.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the information
submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Euflexxa. Our reviewer says that
Euflexxa (J7323) is not medically reasonable and necessary for the enrollee. Our physician reviewer found
based on the medical records provided the enrollee has not tried and failed the required drugs, Orthovisc and
Monovisc. Our reviewer also found that there is no indication that the Plan's required drugs would likely be less
effective and/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 Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa (J7323).
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 you would like this claim reconsidered for medical necessary. 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 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. The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD 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 SNF services after May 5, 2021.

You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the member does not have a range of motion and is not familiar with walking with a walker at this time. The Plan denied your request. The Plan says the member no longer requires skilled services so the continuation of SNF services is not medically 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this beneficiary 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services after May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.
You asked the Plan to pre-approve a seat lift mechanism. You say that the enrollee requires the seat lift mechanism The Plan denied your request. The Plan says there is no documentation that completely incapable of standing up from a regular armchair or any chair in their home.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. We asked our 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 seat lift mechanism. Our reviewer says that the seat lift is not proven necessary. Our reviewer found there is no documentation that provides a clinical assessment indicating member is completely incapable of standing up from a regular armchair or any chair in their home. 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 seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal cord stimulator (CPT code 63650) to be
performed by an out-of-network provider.

You asked the Plan to pre-approve the stimulator. You say that the services are necessary. The Plan denied
your request. The Plan says the Medicare rules have not been met and the provider is not in-network with the
Plan.

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
spinal cord stimulator (CPT code 63650) to be performed by an out-of-network provider.