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

We decided that the Plan does not have to pre-approve a group 2 power operated vehicle (POV) (K0807).
You asked the Plan to pre-approve a group 2 POV. You say that you are not able to get far using your cane. The Plan denied your request. The Plan says this specific POV is not covered.
The Plan must follow Medicare rules. Medicare rules say that group 2 POVs (K0806, K0807, K0808) have added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 2 POV have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power operated vehicle (POV) (K0807).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested device. You say that the enrollee is at risk for hypoglycemia and needs frequent monitoring. The Plan denied your request. The Plan says the requirements have not been met.
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 does not show that the enrollee uses 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 the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient admission for ketamine infusions.

You asked the Plan to pay for the inpatient admission. You say that this admission should be approved to provide this drug infusion. The Plan denied your request. The Plan says there is no valid reason given that the infusion cannot be provided in the outpatient setting.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 the inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the enrollee is a female with a history of migraine headaches. There is no specific clinical rationale for inpatient hospital services for the ketamine infusion. The review has determined that the record does not show that the admitting physician reasonably expects that the patient's necessary hospital care will span two midnights. 

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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient admission for ketamine infusions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an out-of-network urologist.
You asked the Plan to pre-approve the office visit. You say that you need to see a doctor out-of-network. The Plan denied your request. The Plan says in-network providers are available.
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 an office visit with an out-of-network urologist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found 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 the skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 cholelithiasis. Her 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 an 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient skilled nursing facility admission.

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 care. Our reviewer says that an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. You have no complex wound care or other skilled nursing need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing and skilled therapy services are not required on a daily basis or as a practical matter on an inpatient basis, in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.

You asked the Plan to pre-approve the requested services. You say that the minimally invasive procedure is a safer alternative. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.

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 requested services. Our physician reviewer found that the requested device is considered experimental. Additional research is needed to show safety and efficacy. Therefore, the requested interspinous device 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on November 24, 2020.

You asked the Plan to pay for the eye refraction. You say that the provider in question is part of the Plan's
routine vision benefit network and these services should be covered. The Plan denied your request. The Plan
says this request was not submitted to the appropriate entity, and therefore cannot be covered by the Plan.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when they are provided as part of a routine vision exam provided by a
provider in the supplemental vision benefit vendor's network and are submitted directly to the appropriate
vision vendor.

We looked at the file and the Plan's rules. The Plan has indicated that the claim was not submitted correctly for
processing. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on
November 24, 2020.

Please note: After this review was requested, the claim was correctly submitted to the vision benefit vendor and
will be reviewed under that portion of the Plan. Contact the Plan or the Plan's routine vision vendor for more
information about this request under the Plan's supplemental vision benefit.
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 would benefit from IRF care to return him to his prior level of function. The Plan denied your request. The Plan says the enrollee is medically stable and does not require intensive therapy to meet goals.
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 the patient was admitted for coronary artery bypass grafting. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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 acute inpatient rehabilitation facility (IRF) admission and services.
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 these services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for IRF 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for encephalopathy and dehydration. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not support insulin injections three or more times per day.

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 monitor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a requirement for checking blood glucose levels four times a day, and taking three shots of insulin daily with frequent dose adjustments based on blood glucose readings. This criteria has not been met, as the enrollee is taking insulin two times a day, and is not checking four times a day. There are no extenuating circumstances present that would preclude the use of a glucometer. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rollator walker.

You asked the Plan to pre-approve a rollator. You say that the wheelchair is used to go out, and the walker is used at home. The Plan denied your request. The Plan says the enrollee has a similar equipment for the same medical needs.

The Plan must follow Medicare rules. The rules 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.

The file shows that the enrollee has a manual wheelchair. The wheelchair serves the same purpose as the requested rollator. Therefore, we decided that the Plan does not have to pre-approve a rollator walker.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve routine transportation. You say that you need more trips due to being legally blind. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation trips is correct, because routine transportation beyond 30 one-way trips per year is not covered by the Plan.

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 30 trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, once you receive 30 covered one-way routine transportation trips your routine transportation benefit will be exhausted. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3320) and a post and core in addition to a crown (D2954).

You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says 1 root canal is covered every 60 months. The Plan says 1 post and core in addition to a crown is covered every 60 months. The Plan also says that the frequency limits have been reached.

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 and the services are listed as covered, the frequency limits have been reached. The record shows that the Plan paid for these services that you received on March 22, 2021. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3320) and a post and core in addition to a crown (D2954).
Appeal type: Other
Decision: Favorable

We decided that the Plan has to pre-approve the coronary artery catheter placement.

You asked the Plan to pre-approve the coronary artery catheter placement. You say that you would like
reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan
says that the records do not show that the member's symptoms persisted but did not worsen following a 12
week trial of treatment.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 the coronary artery catheter placement.
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this
case. Our physician reviewer found the member is having exertional angina type symptoms while on multidrug
guideline directed medical therapy for angina. Her baseline EKG is abnormal and her stress test is positive for
ischemia. Her blood pressure is well controlled on medications and she reports symptoms despite this adequate
medical therapy.

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 coronary artery catheter placement have been met. Therefore, we decided
that the Plan has to pre-approve the coronary artery catheter placement.

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.