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

We decided that the Plan does not have to pre-approvean inpatient skilled nursing facility (SNF) admission.You asked the Plan topre-approveSNF care. You say that an inpatient skilled nursing facility admission is medically necessaryfor the enrollee.The Plan denied your request. The Plan says that the enrollee doesnot 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 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 care. Our reviewer says that an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that the enrolleedoesnot require skilled nursing or skilled therapy services on a daily basis. Additionally, hedoesnot meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plandoes not have to pre-approvean inpatient skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay foracute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pay forIRF care. You say that inpatient rehabilitation is medically necessary.The Plan denied your request. The Plan says the rules for coverage have notbeen met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is already ambulating more than 100 feet and tending to ADLs with minimal supervision. The enrollee's care needs can be met at a lower level of careWe 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 pay foracute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesilver collagen wound dressing.You asked the Plan to pre-approvethe requested items. The Plan denied your request. The Plan says the dressing is not considered effective for wound care.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The rules say that the safety and effectiveness of silver has not been established. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approvesilver collagen wound dressing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator. You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need a portable oxygen concentrator to get outside and to your appointments. The Plan denied your request. The Plan says oxygen services are for in-home use only.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.
We looked at the file and Medicare rules. The portable oxygen concentrator is being requested for use outside the home. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete maxillary denture and a complete mandibular denture.You asked the Plan to pre-approvethe complete maxillary and mandibular dentures. You say that thedentures are necessary.The Plan denied your request. The Plan says the necessary x-rays were not received.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 complete maxillary and mandibular dentures 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 complete maxillaryand mandibular dentures. Our reviewer says that the dentures are not medically necessary. Our physician reviewer found the documentation submitted was not adequate to meet the criteria for coverage for complete maxillary and mandibular dentures. The criteria for a complete radiographic series or a panographic series is required. A request for additional information was sent but the information was not received.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 complete maxillary and mandibular dentures have not been met.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture and a complete mandibular denture.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Neulasta.You asked the Plan to pre-approveNeulasta. The Plan denied your request. The Plan saysthat coverage criteria have not been met.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. Weasked 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 Neulasta. Our physician reviewer found that the requested use of Neulasta is FDA-approved for the enrollee's diagnosis. The enrollee has a greater than 20% risk of neutropenic fever based on regimen of carboplatin and paclitaxel, ageof greater than 65, and prior chemotherapy. The documentation support that the requested drug is safeand effective and otherwise reasonable and necessary for this enrollee. Therefore, the requested drug is medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta have been met.Therefore, we decided that the Plan has to pre-approveNeulasta.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional occupational therapy services for the
enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 services. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found when the enrollee plateaus and becomes functional, as is the case
here, the requested therapy is not generally accepted as specific and effective therapy. After the home exercise
program, the enrollee should be capable of maintaining their level of activity. The enrollee does not meet
coverage criteria for continued therapy by an OT beyond 6/4/20.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional occupational therapy services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metaxalone.You asked the Plan to pre-approve Metaxalone. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Metaxalone.Benefits for Metaxalone 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 pay for the skilled nursing services provided from January 24, 2020 to February 22, 2020. You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF 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 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 24, 2020 to February 22, 2020.
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 you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says an inpatient skilled nursing facility admission 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 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 care. Our reviewer says that an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that the enrollee does not require skilled nursing or skilled therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you are requesting a reconsideration of the Plan's denial.The Plandenied 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 IRF admission is covered only when it is medically reasonable and necessary as described above.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 enrollee is medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician or a need for acute rehabilitation nursing care. The enrollee does not qualify for an IRF stay as due to Dementia, there will be no carryover of the functional skills learned. The enrollee's rehabilitation needs can be met at a lower intensity setting. An IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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-approvean acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the dental services provided on March 5, 2020.
You asked the Plan to provide additional payment for the dental services. You say that you are upset the Plan only paid a portion of the bill. The Plan denied your request. The Plan says that the out of network liability was applied correctly.
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 says that you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider. We looked at the file and Medicare rules. The file indicates you went to an out-of-network provider and the plan paid up to the MAC. You are responsible for any charges over that amount. Therefore, we decided that the Plan does not have to provide additional payment for the dental services provided on March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface.
You asked the Plan to pre-approve a home ventilator (E0466). You say that the enrollee needs a home ventilator. The Plan denied your request. The Plan says the clinical information provided did not support the medical necessity for a home ventilator.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a home ventilator (E0466). Our reviewer says that a home ventilator is not medically necessary. Our physician reviewer found coverage criteria for a home ventilator are not met. This enrollee has severe COPD with chronic hypoxic respiratory failure, but there is no documentation of increased pCO2 by arterial blood gas while stable. There is no documentation of failure of BiPAP. The enrollee was treated with BiPAP during a recent hospitalization, with improvement. Medicare does not cover a home ventilator when used as BiPAP. A home ventilator is not medically necessary, and the denial is upheld. 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 home ventilator (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Cologuard Multitarget Stool DNA test.You asked the Plan to pre-approve the test. You say that you are in a higher risk group because of your age.The Plan denied your request. The Plan says there is a personal history of adenomatous polyps.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 test. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are not at average risk for developing colorectal cancer. You have a personal history of a tubular adenoma.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 test have not been met.Therefore, we decided that the Plan does not have to pre-approve the Cologuard Multitarget Stool DNA test.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets the criteria
for coverage of LTACH care. The Plan denied your request. The Plan says the records show the enrollee still
needs monitoring for confusion and bleeding in the brain. The Plan says that the enrollee is still on a
medication to stay sedated. The Plan says that the enrollee needs to stay in the hospital until he is better
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 says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) 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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 you required moderate to maximum assistance for transfers. You are able to walk 15 feet with a wheeled walker. You required minimum assistance for activities of daily living with dizziness and fatigue. You are medically stable. The documentation does not support that you require an intensive rehabilitation therapy program. You may benefit from further skilled physical therapy and occupational therapy but do not require treatment in an IRF. Your care needs can be met 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary, as the enrollee is not a candidate for biphosphonate.The Plan denied your request. The Plan says it is unknown if there has been a trial of intravenous biphosphonate therapy before using Prolia.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the records do not document that the enrollee has had an inadequate response to bisphosphonate therapy (oral or IV) or that the patient is not a candidate for oral and IV bisphosphonate 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 drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.