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

We decided that the Plan does not have to pre-approve ZTlido 1.8% pad.
You asked the Plan to pre-approve ZTlido. You say that this medication has been effective for controlling your pain. The Plan denied your request. The Plan says this drug is not covered under your medical 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 ZTlido 1.8% pad.
Benefits for ZTlido 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthodontist evaluation.
You asked the Plan to pre-approve an orthodontist evaluation. You say that you were told you need an orthodontist evaluation. The Plan denied your request. The Plan says consults and dental services provided by Periodontists and Orthodontists are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an orthodontist evaluation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) brain, including brain stem (70551).
You asked the Plan to pre-approve the MRI. You say that the medical records provided support the necessity of the requested services The Plan denied your request. The Plan says the medical necessity has not been established for the requested MRI at this time.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided documentation, there was no evidence provided of a recent cognitive assessment or lab tests as required prior to considering MRI considering the enrollee's symptoms and presentation having multiple possible etiologies. Therefore, until first line evaluation strategies (labs, cognitive assessment, etc.) MRI will be considered not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) brain, including brain stem (70551).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6245), two retainer crowns (D6740 x2), and bone replacement graft for ridge preservation (D7953) provided on February 25, 2021.
You asked the Plan to pay for the pontic, retainer crowns, and bone replacement graft. You say that you were advised the Plan would only cover $1,000 for dental services. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that your plan does pay up to $1,000 of covered charges.
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 pay for the pontic (D6245), two retainer crowns (D6740 x2), and bone replacement graft for ridge preservation (D7953) provided on February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation feature (E2300) for the enrollee.You asked the Plan to pre-approvea power seat elevation feature. You say that these services are medically necessary.The Plandenied your request. The Plan says that a power seat elevation feature is not primarily medical in nature and not covered.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation feature (E2300) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic ultrasound of the neck (76536) to be
provided by an OON provider.
You asked the Plan to pre-approve the diagnostic service. You say that you have had a lump/bump in your
throat for 3 years which is causing issues with your voice box. At times you are unable to speak due to the
lump/bump. You do not understand why this is being denied. The Plan denied your request. The Plan says
enrollee's must receive their medical services from an in-network provider with the exception being urgent or
emergent services. Non-emergent services with non-contracted providers require prior authorization before
services being rendered.
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
diagnostic ultrasound of the neck (76536) to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on January 26, 2021, by an OON provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 lab services provided on January 26, 2021, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate tab 2.5mg
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is self-administered.
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 Methotrexate tab 2.5mg
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (J0881).
You asked the Plan to pre-approve Aranesp. You say that Aranesp is medically necessary. The Plan denied your request. The Plan says a trial of Retacrit is required before alternatives can be considered.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 Aranesp. Our reviewer says that Aranesp is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug, or any reason the plan preferred drug would be unsafe or ineffective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp (J0881).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insulin Lispro injections 100/ml for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says the medication falls under Part D coverage.
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 insulin Lispro injections 100/ml for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your care can be provided in another setting.
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 physician reviewer found that you were admitted to the acute care hospital for hepatic encephalopathy. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, and an intensive rehabilitation therapy program.
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 a maxillary partial denture (D5213).
You asked the Plan to pre-approve the maxillary partial denture. You say that you lost your denture, and would
like a new one as soon as possible. The Plan denied your request. The Plan says dentures are a covered benefit
and are limited to once every five years.
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, metal and flexible partials (maxillary
and mandibular) are limited to one per arch every 5 years. The record shows that you received a maxillary
partial denture (D5213) on December 9, 2016, and your maxillary partial denture (D5213) benefit has been
exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture
(D5213).
Please Note: You last received a maxillary partial denture (D5213) on December 9, 2016. Five years from this
date would be December 9, 2021, making you eligible for a new maxillary partial denture (D5213) beyond this
date.
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 disagree with the denial. The Plan denied your request. The Plan says the services are 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on June 16, 2021 with chronic obstructive pulmonary disease (COPD) and a urinary tract infection (UTI). The physical therapy note dated July 2, 2021 states she is modified independent with bed mobility and needs contact guard assist with stand up to sit down and walking 10 feet with a two wheeled walker. She 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for you. The Plan denied your request. The Plan says rules for 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 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 daily skilled services are not necessary. Our physician reviewer found that you do require skilled nursing services; that is, the specialized skill, knowledge and judgment of a skilled professional nurse are required to safely and effectively provide medically necessary and reasonable treatment. There are no identifiable skilled therapy service needs. However, it is not medically reasonable and necessary to provide the required skilled nursing services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous loop monitor to be provided by an out of
network (OON) provider.

You asked the Plan to pre-approve a continuous loop monitor to be provided by an OON provider. You say that
you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested
services are neither emergent nor urgent to seek out-of-network care. The Plan says they have confirmed that
the doctor is able to perform the requested procedure at a contracted facility.

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 continuous loop monitor to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre device.
You asked the Plan to pre-approve a Freestyle Libre. You say that you have been using the Freestyle Libre for the past three years and have been extremely happy with it. The Plan denied your request. The Plan says coverage criteria for a Freestyle Libre 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 available documentation does not indicate that you use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided December 30, 2020.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99214 is not supported in the medical record. Specifically, the claim was billed using Place of Service 12- Home. The records show this was an office visit. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met.
Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided December 30, 2020.
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 it is felt that LTACH care would be best for this enrollee. The Plan denied your request. The Plan says the services could be provided in another setting.
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 patient is currently undergoing treatment at an ACH for multiple, embolic, strokes. The enrollee was intubated/ventilated and subsequently received a tracheotomy for long-term airway protection. The enrollee's neurologic status is poor, and it seems unlikely that he will be decannulated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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 the continuation of inpatient mental health care from
June 25, 2021 and forward.

You asked the Plan to pre-approve the continuation of inpatient mental health care. You say that the
continuation of inpatient mental health care from June 25, 2021 and forward is medically necessary. The Plan
denied your request. The Plan says the continuation of inpatient mental health care from June 25, 2021 and
forward is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.

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 inpatient mental
health care. Our reviewer says that the continuation of inpatient mental health care from June 25, 2021 and
forward is not medically necessary. Our physician reviewer found this enrollee did not appear to require
inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and
did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that
active treatment was taking place beyond the date in question. It did not appear that the services were
reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in
question. I am unable to find an individualized treatment plan however the entire chart is not present. It did
appear that the records were supervised and evaluated by a physician. Based upon review of the records
provided the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the
dates in question of June 25, 2021 and forward as this enrollee was not shown to be a danger to herself or
others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with
treatment while not showing any threats to safety.

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 inpatient mental health care have not been met. Therefore,
we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from
June 25, 2021 and forward.