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

We decided that the Plan has to pre-approve bilateral vein treatments for the enrollee.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the enrollee's vein size is less than 4mm, and having right leg saphenous reflux.
The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins of the lower extremity are only covered under certain medical indications. 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 requested services. Our physician reviewer found that reflux in the greater saphenous veins for the most part is absent likely due to the enrollee's previous vein treatments. The isolated areas of reflux are insufficient to meet plan exclusion criteria. Additionally, there are portions of the veins to be treated that meet size criteria of being 4 mm or greater. There is satisfactory documentation that arterial perfusion is adequate. Based on the studies provided, it does not appear that the planned sclerotherapy he would "burn any bridges" with respect to loss of venous conduit should arterial revascularization ever be necessary. The planned sclerotherapy appears to be a very reasonable and focused effort at treating the enrollee's symptoms/condition. The enrollee has recurrent and active ulcers representing a clear, medically necessary, 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 the requested services have been met. Therefore, we decided that the Plan has to pre-approve bilateral vein treatments for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visits provided on July 16, 2019.You asked the Plan to waive the copayment for the podiatry visit. You say that you should not be responsible for the copayment.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each Medicare-covered podiatry service. You have been asked to pay a $40 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the podiatry visits provided on July 16, 2019.Please note, this decision is only in regards to the July 16, 2019 date of service. If you have any questions about other dates of service, please contact the Plan directly.
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. The Plan denied your request. The Plan says that patient does not meet criteria for SNF care.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forautonomic nervous system function testing (95923 and 95924) provided on March 14, 2019.You asked the Plan to pay forautonomic nervous system function testing. You say that this should be covered.The Plan denied your request. The Plan says these codes are not supported by the records.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95923 is testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential and 95924 is testing of autonomic nervous system function; combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt.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 autonomic nervous system function testing. Our reviewer says that CPT 95923 is not supported. The medical records submitted do not include documentation that Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential was performed on March 14, 2019. Therefore, this service cannot be verified. Our physician reviewer found 95924 is not supported. The medical records submitted do not include documentation of Testing of autonomic nervous system function; combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt being performed on March 14, 2019. Therefore, this service cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of autonomic nervous system function testing have not been met.Therefore, we decided that the Plan does not have to pay forautonomicnervous system function testing (95923 and 95924) provided on March 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3310) for tooth # 26, core build up (D2950) for teeth #26 and 28, crowns (D2750) for teeth # 26 and 28, and a root canal (D3320) for tooth # 28.You asked the Plan to pre-approvethe dental services. You say that you waited for your plan to go into effect on January 2, 2020 to request the dental services. You say that you received a letter from the plan saying the services are not covered. You also say that the cost is a lot for you and you are on a fixed income.The Plan denied your request. The Plan says root canals, crowns and core build up are notcovered service.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 dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea root canal (D3310) for tooth # 26, core build up (D2950) for teeth # 26 and 28, crowns (D2750) for teeth # 26 and 28, and a root canal (D3320) for tooth # 28.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-lab split night sleep study.You asked the Plan to pre-approvethe requested testing. You say that because of the CPAP machine, you are unable to get a good night's sleep.The Plan denied your request. The Plan says there is no medical need for an in-lab study.The Plan follows Medicare rules. Medicare rules say that sleep studies are only covered under certain medical indications.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 requested testing. Our physician reviewer found you have mild obstructive sleep apnea, diagnosed on a home sleep study. You were started on CPAP, which was effective in eliminating the sleep disordered breathing. There is no medical necessity for a repeat sleep study with PAP titration as this will not address the intolerance of the interface. Therefore, the requested study 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 the requested testing have not been met. Therefore, we decided that the Plan does not have to pre-approvean in-lab split night sleep study.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plandenied your request. The Plan says the requested admission to a LTACH is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer saysthat the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for failure to thrive. There is concern that the enrollee now has liver disease, which is being further evaluated. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.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 indenying the request to pre-approve admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care on 2/10/20 due to heartburn and confusion, found to have acute cholecystitis. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for pain with effect. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a stand by assist level to supervision level with functional mobility including gait to 150 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs.  There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This 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 admission to a skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional LogistiCare mileage.You asked the Plan to pre-approveadditional LogistiCare mileage. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says you are asking for a total of 160 miles per one-way trip to your destination. The Plan says that your contract clearly states you are only covered for up to 50 miles per one-way trip.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 one-way transportation trips per year, not to exceed 50 miles per one-way trip. We looked at your request, the records in the case file, and the rules. The file shows you are asking for a total of 160 miles per one-way trip to your destination. Your contract clearly states you are only covered for up to 50 miles per one-way trip.Therefore, we decided that the Plan does not have to pre-approveadditional LogistiCare mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe repairs to your power wheelchair (E2386, E2365, E2370, E2387, and K0739).You asked the Plan to pre-approvethe repairs to your power wheelchair. You say that you would like the requested repairs to your current power wheelchair, or a new power wheelchair if the repairs are too costly.The Plan denied your request. The Plan says the repairs to your power wheelchair you are requesting do not meet the requirements for approval. The Plan states the records indicate the chair you need repairs on is kept outside the home and was found to be extremely used. The Plan also noted that a second, functioning, power wheelchair is inside your home and that you want to keep it nice for inside the home.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The rules also say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. You are requesting repairs to a power wheelchair for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Furthermore, the file shows you have a second functioning power wheelchair that you use inside the home. The power wheelchair you use inside the home serves the same purpose as the power wheelchair you want repaired to use outside your home. Medicare will not pay for a power wheelchair when a power wheelchair is already available to you inside your home.Therefore, we decided that the Plan does not have to pre-approvethe repairs to your power wheelchair (E2386, E2365, E2370,E2387, and K0739).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction to be provided by an oral surgeon.You asked the Plan to pre-approvethe extraction. You say that your insurance told you that you qualify for 1 tooth extraction per year.The Plan denied your request. The Plan says dental services provided by an oral surgeon 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 covered when they are received by an oral surgeon. The Plan only covers dental services when they are performed by a participating general dentist.Therefore, we decided that the Plan does not have to pre-approvean extraction to be providedby an oral surgeon.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF admission and services for the enrollee.You asked the Plan to pre-approveSNF services. You say that the enrollee needs to receive therapy to regain maximum function of limbs.The Plan denied your request. The Plan says the enrollee can receive skilled services on an intermittent basis.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 services. Our physician reviewer found that the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee continues to have severe pain, acute medical issues including possibly needing a stent for the bile duct, and treatment for her constipation. These issues require continued acute care monitoring. This enrollee 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 at a SNF levels. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nubeqa 300MG.
You asked the Plan to pre-approve Nubeqa 300MG. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 pre-approve Nubeqa 300MG.
Benefits for Nubeqa 300MG 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Fentanyl patch for the enrollee.You asked the Plan to pre-approvethis drug. The Plan denied your request. The Plan says that this medication does not fall under Part B.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 pre-approvethe Fentanyl patch for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 pre-approve Xifaxan for the enrollee.
Benefits for this drug 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: 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 the enrollee needs therapy to get stronger. The Plan denied your request. The Plan says that the enrollee's needs are mainly custodial.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 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-approveHumira Pen Kit for the enrollee.You asked the Plan to pre-approvethis drug. The Plan denied your request. The Plan says that this is not covered under the member's contract under any normal circumstances.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administereddrugs. 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 pre-approveHumira Pen Kit for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.