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

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
You asked the Plan to pre-approve a HFCWOD. You say that you would like to file an appeal for the denial of 90 day rental. The Plan denied your request. The Plan says the records received does not support medical necessity.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 HFCWOD. Our reviewer says that this treatment with HFCWO is considered not medically necessary. Our physician reviewer found this enrollee has COPD, lung nodules, and recurrent respiratory infections. However, she does not have a diagnosis that is shown to benefit from HFCWO, such as bronchiectasis, cystic fibrosis, or a generalized neuromuscular disease. Recent clinical notes do not indicate a chronic productive cough. 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 HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous laminotomy with decompression of nerve roots (CPT 63020).
You asked the Plan to pre-approve the percutaneous laminotomy with decompression of nerve roots. You say that the enrollee has a nerve that is pinching and causing numbness when she raised her arm. You say that the enrollee loses feeling from shoulder to pinky and ring finger in her arm. You say that the enrollee also has back pain and the requested treatment will help fix more than just the numbness in her arm. The Plan denied your request. The Plan says the requested service is not medically reasonable and necessary.
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 percutaneous laminotomy with decompression of nerve roots. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is insufficient to demonstrate that the requested percutaneous laminotomy with decompression is medically reasonable and necessary for the enrollee in this case. There is insufficient documentation of an adequate trial of conservative management. 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 percutaneous laminotomy with decompression of nerve roots have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous laminotomy with decompression of nerve roots (CPT 63020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the three core buildups, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service is not a covered benefit.
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 the three core buildups, including any pins when required (D2950).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve consultation and surgical treatment for squamous cell carcinoma
of the right mid-back to be provided out of area (OOA).
You asked the Plan to pre-approve the OOA consultation and surgical treatment. You say that you wish to be
allowed to receive this treatment while OOA as you feel it would be a hardship to be required return to the area
for treatment of this condition. Your doctor does not recommend waiting longer than two months for the
excision. The Plan denied your request. The Plan says that you are required to use network providers and if you
wish to be treated for your skin cancer, you must return to the service area.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and
pre-approved care.
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 OOA consultation and surgical
treatment. Our reviewer says that the requested treatment does meet criteria to be considered an urgently
needed OOA medical service. Our physician reviewer found the enrollee received a biopsy immediately prior
to a planned trip out of the service area. The results came back as positive for squamous cell carcinoma while
he was OOA. The OOA consultation and treatment was requested on February 5, 2020 and he is not scheduled
to return to the service area until July 2020.
It would not be reasonable to delay excision of his squamous cell carcinoma for 5 months from the date of the
original request. Given the natural history of most cancers, ideally, excision should be within 4-12 weeks. It is
reasonable and medically necessary for him to receive treatment out of network for this condition.
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 OOA consultation and surgical treatment have been met. Therefore, we
decided that the Plan has to pre-approve consultation and surgical treatment for squamous cell carcinoma of the
right mid-back to be provided out of area (OOA).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of SNF care. You say that a continuation of SNF care is medically necessary and supported by the records provided. The Plan denied your request. The Plan says the requirements for coverage of further SNF care have 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 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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services. Our physician reviewer found that the enrollee does not require skilled therapy services on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) care.
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 documentation provided supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.
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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for a perforated ulcer. Post-operatively, the enrollee developed respiratory failure and renal failure. The enrollee was intubated/ventilated and started on hemodialysis. The enrollee appears to be tolerating ventilator weaning. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 2/11/20 with sepsis due to a urinary tract infection,left pyelonephritis, and influenza A. Treated with Antibiotics, IV fluids and Tamiflu. She was referred to physical therapy and occupational therapy and an admission to an IRF. She is appealing the denial of the admission. Based on review of the available records, the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehab physician or needs acute rehab nursing care. She may benefit from further physical therapy and occupational therapy at home but does not require an intensive therapy program. IRF admission is not medically necessary based on her 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Doppler cardiac ultrasound and referral to an out-of-network provider for a salivary diagnostic test.
You asked the Plan to pre-approve the Doppler cardiac ultrasound and salivary diagnostic test. You say that you have not had a Doppler cardiac ultrasound in the past and the Plan does not offer these services. The Plan denied your request. The Plan says you received a Doppler cardiac ultrasound in May, 2019 and there is no clear documentation that you have heart disease. Additionally, you are contracted to receive services from network providers.
Medicare rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices 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 Doppler cardiac ultrasound and salivary diagnostic test. Our reviewer says that the record indicates that you completed a Doppler Cardiac Ultrasound in May 2019, and there is no clear documentation that you have any heart disease. There is no medical need for the ultrasound to be completed again. Our physician reviewer found salivary metabolomics is a new advancement in the field of salivary diagnostics and is experimental in nature.
Medicare rules also 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 provider at issue 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 the Salivary Diagnostic Test to be rendered out-of-network.
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 Doppler cardiac ultrasound and salivary diagnostic test have not been met. Therefore, the Plan does not have to pre-approve a Doppler cardiac ultrasound and referral to an out-of-network provider for a salivary diagnostic test.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient mental health services rendered on May 29, 2019 to August 29, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the provider type is not covered.The Plan must follow Medicare rules. The rules say that a licensed mental health counselor is noteligible to enroll in Medicare.We looked at the file and Medicare rules. The provider is licensed as a mental health counselor. 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 pay forthe outpatient mental health services rendered on May 29, 2019 to August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 28, 2019.You asked the Plan to pay for the laboratory services. 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 in this case is not a network provider 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 decidedthat the Plan does not have to pay for laboratory services provided on August 28, 2019.
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 IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 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 based on the documentation provided, you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services or that you require regular physician evaluation. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says it is unlikely that three hours of therapy, five days a week will be able to be tolerated.
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT, but the enrollee does not require this on an intensive rehabilitation facility therapy program level 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelengthening of calf muscle for the enrollee.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysphysical therapy should be tried first, before proceeding with this procedure.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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee reports that when she stands for prolonged periods, she feels like she does not have good heel-to-toe gait on the right compared to the left. She is status post right peroneal tendon debridement and calcaneocuboid and subtalar joint fusion in May 2018, with subsequent hardware removal. Clinical exam findings documented "somewhat" of a gastroc contracture with dorsiflexion lacking about 5 degrees. Under consideration is a request for a Strayer procedure, gastrocnemius recession involving lengthening of the Achilles tendon. Current evidence based medical literature generally supports gastrocnemius recession for equinus deformities with dorsiflexion less than 5 degrees with the knee flexed. In this case, there is no clear evidence of a significant gastroc contracture. There is no clear evidence that the enrollee lacks ankle dorsiflexion necessary for normal gait, nor is there a documented gait assessment indicating significant deficits. There is also no evidence that she has failed recent reasonable and/or comprehensive conservative treatment, including exercise, physical therapy, gait training, splints, orthotics, or corrective shoes. Therefore, this request for lengthening of the calf muscle is not medically reasonable and necessary for treatment of the enrollee's medical condition at this time.We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met.Therefore, we decided that the Plandoes not haveto pre-approvelengthening of calf muscle for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have topre-approvecore build up (D2950), periodontal scaling and root planing for 1 to 3 teeth per quadrant (D4342) for all 4 quadrants, and gingival irrigation (D4921) for all 4 quadrants.You asked the Plan to pre-approvethe dental services. You say that the services are listed as covered in your booklet.The Plan denied your request. The Plan says core build up, periodontal scaling and root planing for 1 to 3 teeth per quadrant, and gingival irrigation are not listed as covered services.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvecore build up (D2950), periodontal scaling and root planing for 1 to 3 teeth per quadrant (D4342) for all 4 quadrants, and gingival irrigation (D4921) for all 4 quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture (D5120).
You asked the Plan to pre-approve a complete denture (D5120). You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says your benefit for complete dentures has been exhausted. The Plan says you were provided complete dentures on October 18, 2019, which is less than five years ago.
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 complete dentures (D5120) are not among those covered under this benefit at this time. Your contract with the Plan clearly states you are covered for complete dentures once every five years. The file shows you were provided complete dentures on October 18, 2019, which is less than five years ago. Therefore, we decided that the Plan does not have to pre-approve a complete denture (D5120).