Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 17, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says members must use network (contracted) providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, and cases in which authorizes use of out-of-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 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 decided that the Plan does not have to pay for physician's services provided on September 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar orthosis provided on October 1, 2020.

You asked the Plan to pay for the orthosis. You say that the progress note clearly documents a detailed history and medical necessity.The Plan denied your request. The Plan says the enrollee did not receive a video or telephonic visit by the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity of the item ordered.

We looked at the file, and Medicare rules. This enrollee was contacted via an unsolicited phone call regarding provision of the item at issue. As such, no payment may be made for this item.Therefore, we decided that the Plan does not have to pay for the lumbar orthosis provided on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve therapeutic CGM. You say that the enrollee has been using test strips, and sensors would be easier to use. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic CGM.

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 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. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 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 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 not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 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 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 rules for IRF care have not been 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 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 the enrollee is a 65-year-old male who was admitted to an acute care hospital on April 16, 2021, for foot gangrene. The enrollee 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. The enrollee's 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on November 19, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
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 requested 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 the services provided to the enrollee by an out-of-network
provider on November 19, 2020.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for replacement of a nephrostomy tube. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because the member does not want major back surgery. The Plan denied your request. The Plan says this device is experimental.
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 Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental and more research is needed to show its safety and efficacy. 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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks.
You asked the Plan to pre-approve the medial branch blocks. You say that you would like reconsideration
because the member suffers severe pain with articulation of the facet joints and is unable to perform his
activities of daily living. The Plan denied your request. The Plan says the member has radicular pain, no
documentation of physical therapy and structural causes of pain.
The Plan follows Medicare rules. Medicare rules say that for the medial branch blocks to be indicated, the
member's pain must be predominantly axial and, with the possible exception of facet joint cysts, not associated
with radiculopathy or neurogenic claudication.
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 medial branch blocks. Our reviewer
says that this request does not meet the criteria of the LCD and is therefore not medically necessary. Our
physician reviewer found the member has not had any epidural steroid injections documented.
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 medial branch blocks have not been met. Therefore, we decided that the
Plan does not have to pre-approve medial branch blocks.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued stay at a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF stay. You say that the continued stay is medically necessary. The Plan denied your request. The Plan says the continued stay at the SNF is not medically necessary. The Plan says that the enrollee has not receive any skilled services after February 8, 2021.
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 the SNF stay. 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 SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued stay at a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Coflex Interlaminar Stabilization device.
You asked the Plan to pre-approve a Coflex Interlaminar Stabilization device. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 a Coflex Interlaminar Stabilization device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the coflex device remains experimental for use in spinal surgery. More research is needed to show safety and efficacy. There is no documented instability and hardware is not needed. 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 Coflex Interlaminar Stabilization device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Coflex Interlaminar Stabilization device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve testosterone injections.
You asked the Plan to pre-approve testosterone injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested testosterone injections.
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 testosterone injections. Our reviewer says that the documentation does not support that the requested testosterone injections are medically reasonable or necessary. Our physician reviewer found the enrollee is receiving testosterone 76 mg injections for "menopausal symptoms" and " hormonal imbalance". Nothing more specific is documented in the medical chart. There is no documentation in the medical record explaining why the patient is on testosterone therapy. According to recent Endocrine Society Global Consensus Position Statement on the Use of Testosterone Therapy for Women, the only evidence-based use of testosterone in postmenopausal women is for hypoactive sexual desire disorder and the treatment must not produce testosterone levels that are supraphysiologic such as those obtained by injectables. Therefore, the enrollee does not meet criteria for the requested 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 testosterone injections have not been met. Therefore, we decided that the Plan does not have to pre-approve testosterone injections.
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 these services are medically necessary. The Plan denied your request. The Plan says that your records show that it is not likely that you require hospital-level care for 25 days or more.
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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Our physician reviewer found that your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Boost nutritional supplements.
You asked the Plan to pre-approve nutritional supplements. You say that it is medically necessary for the enrollee to use liquid nutrition on a daily basis. The Plan denied your request. The Plan says the enrollee does not meet the criteria for use of the requested nutritional supplement.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Boost nutritional supplements.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 unspecified restorative services (D2999).

You asked the Plan to pre-approve the dental services. You say that you needed these services.The Plan denied your request. The Plan says unspecified restorative services are not listed as covered. The Plan also says that any services not listed 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 2 unspecified restorative services (D2999).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the enrollee needs this level of care.The Plan denied your request. The Plan says that the member could have been safely managed at a lower level of care.

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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. It is not expected this enrollee would improve in a reasonable period of time as he is not showing any dangerousness to self or others, auditory or visual hallucinations and is without aggressive behaviors while not showing any acute threats of safety. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Yupelri.

You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the drug is not eligible for a tier exception.

The Plan must follow Medicare rules. The rules say that if payment for a drug could be available under Part A or Part B to the individual for such drug, then it will not be covered under Part D.

We looked at the file and Medicare rules. The requested drug is covered by Part B Medicare and not eligible for a Part D tier exception. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a tier exception
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750), endodontic therapy (D3310), maxillary partial denture (D5213), and mandibular partial denture (D5214).
You asked the Plan to pre-approve the crown, endodontic therapy, maxillary partial denture, and mandibular partial denture. You say that these services are medically necessary. The Plan denied your request. The Plan says these services 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 a crown (D2750), endodontic therapy (D3310), maxillary partial denture (D5213), and mandibular partial denture (D5214).