Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 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. LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include tracheostomy care, surveillance laboratory studies, oral anticoagulants, wound vacuum care, nasogastric tube feeding, and therapy services. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission to a SNF.
You asked the Plan to pre-approve the SNF admission. You say that you need to go back to a SNF for more therapy. The Plan denied your request. The Plan says the criteria for SNF services has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of
the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an admission to a SNF.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the face and neck for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is needed as an annual surveillance request. The Plan denied your request. The Plan says that follow-up imaging is only supported once within six months after the completed treatment.
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 MRI is medically reasonable or necessary. Our physician reviewer found while the Evicore guidelines may indicate no necessity for follow-up by MRI in this asymptomatic enrollee after 2 episodes of right parotid gland malignancy, he NCCN guidelines give clinicians a wide choice of follow-up for such cancers. In particular, in an instance of recurrent cancer the guidelines issued by NCCN allow for annual scan surveillance with high-risk cancers such as in this case with a recurrence in the past. As such, MRI is the most sensitive means with which to detect tumor in a deep and difficult to evaluate such as the right parotid gland bed especially after surgery and radiation 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the face and neck for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on June 25, 2020.
You asked the Plan to pay for foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a grab bar provided from May 14, 2020 through May 15, 2020.
You asked the Plan to pay for a grab bar. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a grab bar provided from May 14, 2020 through May 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Filgrastim (Neupogen Solution).
You asked the Plan to pre-approve the Neupogen Solution. You say that the enrollee needs medication for
neutropenic fever and does not need to be hospitalized. The Plan denied your request. The Plan says Neupogen
solution does not meet the criteria for approval.
The Plan follows Medicare rules. Medicare rules say that Filgrastim will be considered medically reasonable
and necessary for the following off-label indications when it is not self/caregiver administered: AIDS
leukopenia in children, amelioration of leukopenia in AIDS patients on AZT, amelioration of leukopenia in
AIDS patients with chorioretinitis on Ganciclovir, intermittent administration of G-CSF for a subset of patients
with myelodysplastic syndromes (MDS) who have severe neutropenia and recurrent infections.
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 Neupogen Solution. Our reviewer
says that Filgrastim is not medically reasonable and necessary for the enrollee. Our physician reviewer found
the requested use of Filgrastim is not a Food and Drug Administration (FDA) approved use. Our reviewer
found that the requested use is not supported or not recommended in any of the compendia. Our physician
reviewer also found that the use for drug induced neutropenia is specifically excluded as not shown to be safe
and effective in LCD L34002.
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 Neupogen Solution have not been met. Therefore, we decided that the Plan
does not have to pre-approve Filgrastim (Neupogen Solution).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 15, 2020, to July 10, 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 did not require 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 June 15, 2020, to July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitoring device, enteral supplies, surgical dressings provided from March 1, 2020, to March 31, 2020.
You asked the Plan to pay for the supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the supplies was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for the glucose monitoring device, enteral supplies, surgical dressings provided from March 1, 2020, to March 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inhalation of nitrous oxide/analgesia, anxiolysis (D9230) and removable dental appliance designed to minimize the effects of bruxism or other occlusal factors (D9946).
You asked the Plan to pre-approve occlusal guard and inhalation of nitrous oxide/analgesia. You say that the service should be covered. The Plan denied your request. The Plan says the services provided are not covered 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. 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 inhalation of nitrous oxide/analgesia, anxiolysis (D9230) and removable dental appliance designed to minimize the effects of bruxism or other occlusal factors (D9946).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from April 21, 2018, to May 20, 2018.
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 April 21, 2018, to May 20, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate maxillary denture (D5130) provided on August 17, 2020.
You asked the Plan to pay for the immediate maxillary denture. You say that you believe this service should have been covered in full. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
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, dentures are limited to 1 per floating 60 months. The record shows that you received a maxillary denture on November 28, 2016, and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the immediate maxillary denture (D5130) provided on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the osseous surgery (D4261), the bone replacement graft (D4263), and the guided tissue regeneration (D4266) provided on March 17, 2020.
You asked the Plan to pay more for the dental services. You say that you received a bill from your provider. You say that the last 2 lines were not approved. You also say that you have a large bill and were expecting it to be lower. The Plan denied your request. The Plan says the bone replacement graft is not listed as a covered service. The Plan says the guided tissue regeneration is not listed as a covered service either. The Plan says the dentist in this case is not a participating dentist. The Plan also says that out of network dentists are allowed to bill the difference of the allowed amount and their billed amount.
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 bone replacement graft and guided tissue regeneration are not among those covered under this benefit. There is a 50% coinsurance for major dental services after the $100 deductible has been met. Additionally, since the services were provided to you
out of network, the provider can bill you for the difference of the allowed amount and their billed amount. Therefore, we decided that the Plan does not have to pay more for the osseous surgery (D4261), the bone replacement graft (D4263), and the guided tissue regeneration (D4266) provided on March 17, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the abdomen including elastography for the enrollee.
You asked the Plan to pre-approve the MRI. You say that an MRI elastography is needed to evaluate the enrollee's medical condition. The Plan denied your request. The Plan says that this is not medically necessary.
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 MRI is medically reasonable and necessary. Our physician reviewer found the enrollee had an enlarged liver on ultrasound at 23.2 cm, and a marked increase in echogenicity. This increased density makes the evaluation of the hepatic parenchyma markedly limited. MR elastography has proven very useful in the evaluation of the stiffness of the hepatic parenchyma and is used to characterize the basis of the abnormal appearance of the liver. The test also is used to evaluate for the presence of portal hypertension and cirrhosis especially in patients with NASH. The use of MR elastography also provides improved visualization of the hepatic parenchyma for masses otherwise not well seen with limited ultrasound. The request for abdominal MRI including elastography is very reasonable and medically necessary and should be approved. 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 been met. Therefore, we decided that the Plan has to pre-approve MRI of the abdomen including elastography for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the implant supported crowns (D6059) for teeth # 18, 19 and 20 provided on February 22, 2020.
You asked the Plan to reimburse you for the dental services. You say that you have not received compensation for the implant supported crowns that you received. You also say that you should be advised if you are not going to receive compensation for these services. The Plan denied your request. The Plan says implant supported crowns are not listed as a covered service.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the implant supported crowns (D6059) for teeth # 18, 19 and 20 provided on February 22, 2020.
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 the SNF services. You say that you are being discharged from the facility too soon. You say that you have too many conditions that need to be addressed and more treatment needs to be completed before coming home. The Plan denied your request. The Plan says the enrollee no longer has any skilled nursing needs and is medically stable. The Plan says that the enrollee has plateaued in regards to physical therapy progress. The Plan says that the further care needed is custodial in nature.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and clear lungs. The enrollee was treated for anxiety. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at contact guard to moderate
assist with functional mobility, including gait to 100 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the 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 the 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital clinic visit provided on May 5, 2020.
You asked the Plan to pay for the outpatient hospital clinic visit. You say that the claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the outpatient hospital clinic visit provided on May 5, 2020.