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.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary.The Plan denied your request. The Plan says rules for 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 a 79-year-old female who was admitted to the acute care hospital (ACH) on March 25, 2021. The patient is currently undergoing treatment at an ACH for respiratory failure in the setting of renal failure and a chronic pressure sore.  The enrollee was intubated/ventilated, receiving a tracheotomy and feeding tube shortly thereafter. 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. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC 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 haveto pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services to be provided by an out of network provider.

You asked the Plan to pre-approve skilled nursing facility services at an out-of-network provider. You say that the requested facility is closer to home and they would allow your spouse to stay at the facility. The Plan denied your request. The Plan says there are available providers that may render the service requested and you are approved for a transfer to an in-network SNF.

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 skilled nursing facility services to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says the enrollee's benefit plan under Medicare allows members to access services from in-network providers only. An exception may be made in case of emergency or if the requested services is not available through the Plan's provider network,or if the provider possess unique skills which are required to adequately care for the member and are not available from in-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 physical therapy services to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a supracapsular nerve block.

You asked the Plan to pre-approve the block. You say that this is medically necessary.The Plan denied your request. The Plan says that there is no diagnosis of complex regional pain syndrome or reflex sympathetic dystrophy.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 block. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you have had suprascapular nerve blocks that have produced greater than 50% relief for 2-3 months. The plan denied the injection as a treatment for peripheral neuropathy. The request is for bursitis, not neuropathy. The request is medically reasonable and necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the block have been met.Therefore, we decided that the Plan has to pre-approve a supracapsular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.

You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered in the SNF.

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 ventilator is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 simple extractions (D7140), 9 surgical extractions (D7210), 4 alveoloplasties in conjunction with extractions (D7310), and 2 bone replacement graft for ridge preservation (D7953).

You asked the Plan to pre-approve the dental services. You say that you went for a second opinion. You say that the oral surgeon advised that there were 2 serious medical problems that he observed. You say that you feel that these services should be covered under your medical insurance as it is now a medical problem. The Plan denied your request. The Plan says the requested services are dental in nature. The Plan says that the requested dental services are not a Medicare covered service. The Plan says that you will be reimbursed up to the maximum of $350 for the extractions. The Plan also says that the bone replacement graft for ridge preservation and the alveoloplasties in conjunction with extractions 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 and extractions are listed as covered, there is a maximum reimbursement amount of $350. Bone replacement graft for ridge preservation and the alveoloplasties in conjunction with extractions are not among those covered under this benefit. Additionally, the services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 18 simple extractions (D7140), 9 surgical extractions (D7210), 4 alveoloplasties in conjunction with extractions (D7310), and 2 bone replacement graft for ridge preservation (D7953).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brow ptosis repair.

You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that in the case of prosthetic difficulties associated with an Anophthalmic, Microphthalmic, or Enophthalmic socket, subjective complaints, examination findings (signs), and failure of prosthesis modification (when indicated) must be documented. 

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 procedure. Our reviewer says that the requested brow ptosis repair is not medically reasonable and necessary. Our physician reviewer found that the medical record indicates that the enrollee has no subjective complaints, and the prosthesis has not required or failed modification. The elements of the coverage rule are not satisfied. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve brow ptosis repair.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve targeted genetic analysis testing.

You asked the Plan to pre-approve genetic testing. You say that you believe this is medically necessary because
of your conditions. The Plan denied your request. The Plan says that the denial of authorization for this testing
is correct, because molecular panel testing to identify targeted cancer treatment is considered investigational.

The Plan follows Medicare rules. Medicare rules state that molecular pathology procedures may be covered if
certain 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 genetic testing. Our reviewer says that
the enrollee meets the Medicare criteria for the requested genetic testing. Our physician reviewer found per the
National Comprehensive Cancer Network (NCCN) guidelines for myelodysplastic syndromes, additional
molecular and genetic testing for hereditary hematologic malignancy predisposition in a subtest of patients,
particularly in younger patients, are recommended. You have unexplained Cytopenias. This testing is medically
reasonable and necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of genetic testing have been met. Therefore, we decided that the Plan has to pre-approve
targeted genetic analysis testing.

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 pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is medically necessary. The Plan denied your request. The Plan says rules for a therapeutic continuous glucose monitor 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 documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the contact lenses (V2531).

You asked the Plan to pre-approve the contact lenses up to $900. You say that the requested contact lenses are medically necessary. The Plan denied your request. The Plan says the amount requested in is excess of the $600 benefit allowance for the 2021 plan year.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to $600 towards contact lenses. The member will be responsible for any amount over the $600 allowance. 

We looked at the file and the Plan's rules. The Plan has a $600 allowance limit for contact lenses. The requested contact lenses are $900, and therefore are in excess of the Plan's supplemental benefit. The Plan has stated that the requested contact lenses would be eligible for coverage up to the $600 limit. Therefore, we decided that the Plan does not have to pre-approve $900 for the contact lenses (V2531).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zoledronic Acid.

You asked the Plan to pre-approve Zoledronic Acid. You say that this drug is medically necessary. The Plan
denied your request. The Plan says coverage would require enrollee to continue taking cancer drugs.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Zoledronic Acid. Our reviewer says
that the request is not medically necessary and reasonable. Our physician reviewer found the use of Zoledronic 
acid requires concomitant use of calcium and vitamin D. The documentation does not note that the enrollee is
using calcium and vitamin D. Therefore, the requested Zoledronic acid is not shown to be medically necessary
or reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Zoledronic Acid have not been met. Therefore, we decided that the Plan does
not have to pre-approve Zoledronic Acid.
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 your treatment team is recommending IRF to improve function in order to return home. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct.

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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay 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 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 considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical
records provided you do not require an intensive inpatient rehabilitation therapy program. There is no
documentation that you require the intensive rehabilitation therapy program provided in an inpatient
rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case.

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 IRF admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ranibizumab injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that this injection is considered experimental, investigational, and unproven for the treatment of all other retinal vascular disorders.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found the documentation supports that this drug is safe and effective for the enrollee. Ranibizumab is indicated and FDA-approved for the treatment of neovascular age-related macular degeneration.

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 injection have been met. Therefore, we decided that the Plan has to pre-approve Ranibizumab injection 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: 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 does need ongoing care but now can get care at a different level such as a skilled nursing facility or long-term care.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pull-up diapers.

You asked the Plan to pre-approve incontinence supplies. You say that this is needed due to incontinence. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve pull-up diapers.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Glumetza for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not covered Part B.

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 Glumetza for the enrollee

.Benefits for this drug may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.