Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that you are not satisfied with the outcome of a decision. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift 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 stair glide.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pradaxa Cap.
You asked the Plan to pre-approve Pradaxa Cap (J8499). You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug 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 pre-approve Pradaxa Cap.
Benefits for Pradaxa Cap (J8499) 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 27, 2020.
You asked the Plan to pay for the ambulance services. You say that you had a medical emergency, you were
covered in bees and received multiple stings on your hands and face. The Plan denied your request. The Plan
says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on August 27, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 27,
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 17, 2021.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 17, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your rehab and medical needs can be met with part-time skilled services in a lower level of 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluid flow and arthrocentesis of the hip.
You asked the Plan to pre-approve Fluid flow or fluid gf, 1 cc (Q4206) and Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (20610). You say that the enrollee has pain around the trochanter and this is the best course of treatment. The Plan denied your request. The Plan says there are not enough studies on amniotic fluid in the hip to show it is safe and effective.
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 Fluid flow or fluid gf, 1 cc (Q4206) and Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (20610). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for Fluid flow or fluid gf, 1cc (Q4206) and arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee subacromial bursa); without ultrasound guidance (20610) is 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 Fluid flow or fluid gf, 1 cc (Q4206) and Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (20610) have not been met. Therefore, we decided that the Plan does not have to pre-approve Fluid flow and arthrocentesis of the hip.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a round trip non-emergent transportation from home to a medical appointment.
You asked the Plan to provide coverage for the round trip non-emergent transportation from home to a medical appointment. You say that you do not need assistance walking to and from or getting in and out a car. You say that you have no other way to get to this neurology appointment in Boston for migraines. The Plan denied your request. The Plan says non-emergent transportation may be authorized when criteria such as; you must be
unable to ambulate with or without assistance; or unable to ambulate with or without an assistive device; or require assistance getting to a vehicle, and into, or out of a vehicle can be met. Based on the information provided by you and your provider we have concluded that you do not meet the criteria.
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. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of non-emergent transportation have not been met. Therefore, we decided that the Plan does not have to provide coverage for a round trip non-emergent transportation from home to a medical appointment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you can no longer walk without severe pain in both your feet and ankles. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and extraction (D7210) to be provided by an oral surgeon.
You asked the Plan to pre-approve the comprehensive oral evaluation and extraction. You say that you would like these services to be provided by an oral surgeon. The Plan denied your request. The Plan says consults and extractions provided by oral surgeons, periodontists, endodontists, other dental specialists, or non-network general dentists 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. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and extraction (D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) and core build up (D2950) for tooth #
29.
You asked the Plan to pre-approve the dental services. You say that it is hard to chew without teeth. You say
that they want you to do a root canal. You say that you are getting rid of that tooth. You also say that tooth # 29
is coming out and the crown will go on the other tooth. The Plan denied your request. The Plan says tooth # 29
has a poor prognosis. The Plan also says that the crowns do not meet the criteria for coverage.
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. The Plan covers the dental
services when the services are medically necessary and reasonable.
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 dental services. Our reviewer says
that the core build up and crown are not medically necessary. Our physician reviewer found the provided
documentation indicates the presence of a crown on tooth # 29 with distal decay. The reviewer found that the
caries extends sub-crestal. The reviewer also found that tooth # 29 has a poor prognosis for retention.
Therefore, the reviewer found that the requested core build up and crown are not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and core build up (D2950) for tooth # 29.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0800).
You asked the Plan to pre-approve a power wheelchair. You say that the item is medically necessary. The Plan
denied your request. The Plan says the required documentation had not been received.
The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must
furnish to the intermediary or carrier sufficient information to determine whether payment is due and the
amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of these services have not been met. Specifically, there are no medical records provided in this case.
Without the medical records, we cannot review to see if the services are medically necessary. The records
indicate the Plan made several attempts to receive the required documentation. Therefore, we decided that the
Plan does not have to pre-approve a power wheelchair (K0800).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided from February 2, 2021,
through February 4, 2021.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered
benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on February 2, 2021 to February 4, 2021. The
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services
provided from February 2, 2021, through February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee requires medical oversight by a rehab nurse and physiatrist and requires an intensive therapy program to achieve maximum results to discharge home. The Plan denied your request. The Plan says the clinical documentation does not indicate that the enrollee would require medical oversight by a physician or nurse at least three times per week. The enrollee's medical condition appears stable. Th enrollee would benefit from therapy; however, it does not appear that the enrollee would be able to participate in intensive therapy at the acute inpatient level. The necessary care can be provided at a lower level.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablations (RFAs) of cervical levels C2-C5 and bilaterally at lumbar levels L4-L5 (procedure codes 64633, 64634, and 64635).

You asked the Plan to pre-approve radiofrequency ablations. You say that you have extreme medical issues and these radiofrequency ablations are suggested to be performed in several areas and need to be more than twice per area per year. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the enrollee exceeds the limits for RFAs in covered spinal regions.

The Plan follows Medicare rules. Medicare rules state that Medicare will not cover more than 2 radiofrequency sessions per covered spinal region per rolling 12 months. 

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 radiofrequency ablations. Our reviewer says that you do not meet the Medicare criteria for the requested radiofrequency ablations. Our physician reviewer found this request exceeds the Medicare utilization requirements and; therefore, is considered not medically reasonable or necessary 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 radiofrequency ablations have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablations (RFAs) of cervical levels C2-C5 and bilaterally at lumbar levels L4-L5 (procedure codes 64633, 64634, and 64635).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you are experiencing weakness in the legs after an injury, which caused you to further injure yourself. Admission to an IRF is necessary for you to regain your strength and prior level of function. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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 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 continued skilled nursing facility (SNF) services for the
enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that there are no noted daily skilled complex nursing or therapy needs
which would meet the guidelines for continued SNF services.

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 that the enrollee's condition does not
meet Medicare criteria for continued 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 continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF is necessary for managing your conditions and providing therapy. You say you do not feel safe to go home. The Plan denied your request. The Plan says your records indicate that it is not reasonable to expect that you will be able to fully benefit from the intensity of services at an IRF. You do not require an intensive and complex interdisciplinary approach to your rehab, and it is not reasonable to expect that you would be able to actively participate safely in 3 hours of therapy 5 days a week. You can safely receive the necessary services in another setting, such as a skilled nursing facility or at home with home health services.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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 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.