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

 
We decided that the Plan does not have to pre-approve Advair inahler. 
 
You asked the Plan to pre-approve Advair inahler. 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 Advair inahler.  
 
Benefits for Advair inahler 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. 
 
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 complex medical needs requiring skilled nursing services. 
 
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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination of the foot provided on December 
21, 2019. 
 
You asked the Plan to pay for the radiologic examination of the foot. The Plan denied your request. The Plan 
says the Plan requires utilization of network providers when possible and available, and requires authorization 
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider and the referring physician in this case are not network providers with the Plan. The 
Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for 
these services. Therefore, we decided that the Plan does not have to pay for a radiologic examination of the foot 
provided on December 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) services.
You asked the Plan to pre-approve the CT scan. You say that the CT was requested as part of a pre-operative work up for the enrollee's thickened endometrium, growing fibroids, and post-menopausal bleeding. You say that you would like to image the abdomen and pelvis to evaluate for possible sarcoma, given her growing fibroids after menopause. The Plan denied your request. The Plan says the documentation does not meet the criteria for medical necessity.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found a CT abdomen/pelvis was requested as part of a pre-operative work up for the enrollee's thickened endometrium, slightly growing fibroids based on ultrasound, and post-menopausal bleeding for three years looking for possible sarcoma. An MRI of the pelvis from June 20, 2020 showed myomatous uterus, abnormal endometrial thickening, no adnexal lesion or lymphadenopathy. A biopsy of the endometrium was performed on August 7, 2020 showing inactive endometrium and unremarkable endocervical and squamous epithelium. Besides ultrasound and endometrial biopsy, current standard of care includes imaging with MRI when tumor growth occurs in postmenopausal women who are not on hormonal replacement therapy. MRI had already been completed without mention of suspicious-looking tumors and endometrial and cervical biopsy was normal. There was insufficient justification made for the CT scan 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 the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network
provider.
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
a second opinion to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you have used all 12 one-way trips for the 2020 calendar year.
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 12 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiovascular services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the enrollee's prognosis with continued medical therapy alone is very grim. The Plan denied your request. The Plan says there are network providers 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve cardiovascular services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brain imaging, positron emission tomography (PET); metabolic evaluation (78608).
You asked the Plan to pre-approve the PET scan. You say that the provider would like to investigate and help you with your dementia diagnosis and better understand your worsening condition. The Plan denied your request. The Plan says the imaging is not 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 PET scan. Our physician reviewer found the records provided for review did not indicated that the member is suspected of having either AD or FTD (let alone both diagnoses). Rather, the notes provided for review suggest that the member has previously been suspected of having vascular dementia (in the setting of other medical conditions). Given that the records do not suggest that the member meets diagnostic criteria for both AD and FTD, this service would not be eligible for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve brain imaging, positron emission tomography (PET); metabolic evaluation (78608).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ORA Verifeye procedure.
You asked the Plan to pre-approve ORA Verifeye. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this testing is not medically necessary and not covered during cataract surgery.
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 ORA Verifeye. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found it has not been demonstrated that ORA Verifeye would impact the eye health of this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ORA Verifeye have not been met. Therefore, we decided that the Plan does not have to pre-approve an ORA Verifeye procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested second opinion.
You asked the Plan to pre-approve the second opinion. The Plan denied your request. The Plan says the services are available in-Plan and the member is contractually required to obtain this service from network providers.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested second opinion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested ophthalmological services.
You asked the Plan to pre-approve the ophthalmological services. You say that this provider performed cataract surgery of your left eye prior to enrollment with this Plan. You say that you would like this provider to evaluate your right eye since you are an established patient. The Plan denied your request. The Plan says coverage with out-of-network providers is allowed only when the service is medically necessary but unavailable within the network or in an emergency.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested ophthalmological 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 the enrollee would greatly benefit from and be able to tolerate 3 hours of therapies for 5-7 days a week. You say that an IRF would be able to teach the enrollee proper and safe transfer techniques, allowing the enrollee to return home safely. You say that the enrollee is young, hardworking and willing to complete the IPR program. The appellant says that the clinical documentation supports the need for IRF care. The Plan denied your request. The Plan says IRF care 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 the enrollee was not medically quite stable and has no need for acute rehab nursing care. Functionally, given his current level, while he needs physical therapy and occupational therapy, he does not require IRF level of therapies when he cannot tolerate them. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. The enrollee is not likely to be able to fully participate in and benefit from IRF care until he has better pain control and weight bearing on the left lower extremity. The enrollee's rehabilitation needs can be met at a lower intensity alternate setting such as in a skilled nursing facility. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service you became 
unresponsive and your wife called for an ambulance because she felt you were having a low blood sugar attack. 
You say that when the emergency responders arrived, they took your blood pressure and temperature and found 
them to be in normal ranges. You stated that you were feeling better and so you declined transportation to the 
emergency room. You say that you have now received a bill for the ambulance services, and you would like the 
Plan to cover the services. You stated that you did not want or use the ambulance and you feel that you are 
being unfairly billed for the services. You asked the Plan to reconsider their decision because you believe it 
was an emergency service. 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 November 4, 2019. 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.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three further home health skilled therapy visits. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says services are approved through September 4, 2020; three further visits are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the three visits are not medically necessary. Our physician reviewer found the enrollee has had 36 home 
physical therapy visits since April of 2020. The visit on July 31, 2020 states that the enrollee did a few 
exercises and said he did not want to do any further exercise. He was instructed in a home exercise program 
and walked 250 feet in his house with no assistive device. He was instructed on a physical therapy program. 
The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's level of function or to prevent deterioration. The enrollee's functional 
level does not require three further skilled therapy visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve three further home health skilled therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a lumbar ESI is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee presented with continued low back pain rated at eight out of 10. The pain worsens with activing. Imaging shows severe spondylotic changes, moderate central canal stenosis at L4-5 with left prominent disc spur. Multilevel high grade neural foraminal narrowing worse at L4-5 and L5-S1 left side. Conservative treatment with physical therapy in the past has had no benefit. There is no documentation of pain relief of at least three months' duration with previous injection therapy; therefore, the lumbar ESI is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the purchasing of a bipap machine (E0470).
You asked the Plan to pre-approve the purchasing of a bipap machine (E0470). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee has not met criteria for the purchase of a bipap device at this time.
The Plan must follow Medicare rules. Medicare rules say in order for continued coverage of a PAP device (E0470) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy. We looked at the file and Medicare rules. The file shows that the usage compliance criteria had not been met in order to purchase the bipap. The Plan has approved one additional month of rental to allow the enrollee an additional opportunity to demonstrate successful compliance. Based on this information, we decided that Medicare rules for coverage of the purchasing of a bipap machine (E0470) have not been met. Therefore, we decided that the Plan does not have to pre-approve the purchasing of a bipap machine (E0470).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial dentures and a bone replacement graft.
You asked the Plan to pre-approve dental services. You say that your present denture makes your gum sore and it is difficult to chew food. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because you previously had a partial denture on June 22, 2017 and therefore this benefit is currently exhausted, and because bone replacement graft is not covered by the Plan's dental benefits.
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 partial denture code D5212 one per patient per 60 months. The Plan does not cover bone replacement graft code D7953. You received a partial denture on June 22, 2017, therefore 60 months have not passed since this service was covered and the benefit is currently exhausted. Additionally, the requested bone replacement graft is not covered by the Plan. Therefore, we decided that the Plan does not have to pre-approve partial dentures and a bone replacement graft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 100 day supply of lancets.
You asked the Plan to pre-approve a 100 day supply of lancets. You say that the enrollee needs more than the usual utilization amount. The Plan denied your request. The Plan says the allowed number of lancets and testing supplies are limited to 450 lancets per 90 day supply.
The Plan must follow Medicare rules. Medicare rules say that supplies greater than 90 days will not be authorized. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a 100 day supply of lancets have not been met. Therefore, we decided that the Plan does not have to pre-approve a 100 day supply of lancets.