Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional five (5) outpatient PT visits.

You asked the Plan to pre-approve an additional five (5) outpatient PT visits. The Plan denied your request. The Plan says based upon the clinical notes reviewed the member does not meet medical necessity guidelines.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 an additional five (5) outpatient PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition.

Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee and the staff have been provided instruction on enrollee's functional needs. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional five (5) outpatient PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional five (5) outpatient PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple first 15 minutes of anesthesia (D9222).

You asked the Plan to pre-approve the multiple first 15 minutes of anesthesia. You say that you would like the anesthesia to be approved for coverage. The Plan denied your request. The Plan says there are no approved procedures being performed in association with the anesthesia.

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 multiple first 15 minutes of anesthesia (D9222).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bifocal lenses received on December 7, 2020.

You asked the Plan to pay for bifocal lenses. You say that you were unaware that you did not have vision coverage. The Plan denied your request. The Plan says the service at issue is not covered. You were not enrolled in the optional supplemental benefits for the date of service.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.

The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for bifocal lenses received on December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre 14-day sensor kit

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. The rules say that a continuous glucose monitor is covered under certain
specific indications.

We looked at the file and Medicare Rules. Based on this information, we decided that Medicare rules for the
services at issue have not been met. Specifically, the case file did not contain medical records for the requested
services. There is no way to determine if the criteria have been met for the requested monitor. Without the
medical records, the billed services cannot be verified. Therefore, we decided that the Plan does not have to
pre-approve the Freestyle Libre 14-day sensor kit
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 you need LTACH care. 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 There is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care facility. You do not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that these additional trips are necessary. The Plan denied your request. The Plan says after your remaining 8 trips have been used, the benefit will have been exhausted.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that after you have used your remaining trips you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the dental services provided from September 20, 2019, to November 19, 2020.

You asked the Plan to pay more for the dental services. You say that you believe these services should be covered. The Plan denied your request. The Plan says your maximum dental benefit has been met for the 2019 and 2020 plan 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, the Plan offers a $1,000 dental benefit every year for Non-Medicare covered preventive and comprehensive dental services combined. The contract also says that you are responsible for any amount above the dental coverage limit. The Plan paid $1,000 toward your dental services in both 2019 and 2020, and since the Plan paid the maximum amount you are responsible for the remaining balance. Therefore, we decided that the Plan does not have to pay more for the dental services provided from September 20, 2019, to November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positioning cushion for the enrollee.

You asked the Plan to pre-approve the cushion. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered a comfort and convenience item.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a positioning cushion for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peripheral arterial disease pneumatic compression device (E0675).

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the medical usefulness of this device is not established.

The Plan must follow Medicare rules. The rules say that a device coded as E0675 will be denied as not reasonable and necessary. Medicare rules say that items and services that are not medically necessary are not covered.

The requested device is statutorily not covered. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a peripheral arterial disease pneumatic compression device (E0675).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says you have used 56 of the allotted 60
transportation trips for the 2021 benefit year. The Plan says that additional transportation trips will not be
approved.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 60 one-way transportation trips per year.

We looked at your request, the records in the case file, and the rules. The file shows that you have used 56 of
the allowed 60 one-way trips. You have 4 one-way trips remaining until you have exhausted this benefit.
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three skilled nursing visits and one occupational therapy visit.

You asked the Plan to pre-approve these services. You say that you need to regain your strength. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the medical record dated May 24, 2021 states that you do not need routine monitoring. The records do not support that you require skilled nursing services or skilled therapy services to effectively provide treatment, care, and/or services to improve your condition or to establish a maintenance program. The requested home health services are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve three skilled nursing visits and one occupational therapy visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.

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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no
documentation provided necessitating admission to a LTACH. 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 she is currently receiving care. There are no services available at the LTACH that the
enrollee requires that are not available at the health care setting being offered by the health plan. The requested
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of
the enrollee.

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 LTACH 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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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
enrollee does not meet criteria for IRF admission. 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 congestive heart failure.
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, in 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.

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 inpatient admission to a mental health facility.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there is no imminent danger to self.

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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not meet the criteria for acute inpatient mental health treatment beyond the dates in question, as you could have been treated in a lesser restrictive setting. You were not showing suicidal/homicidal ideation, auditory/visual hallucinations, or delusions. You were not showing any behaviors or aggression, as you were being cooperative and compliant, while not showing any acute 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission to a mental health facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional 15 minutes of intravenous (IV) sedation (D9243) provided on December 2, 2020.

You asked the Plan to pay for the IV sedation. You say that you received IV sedation for oral surgery. You say that it should be covered. The Plan denied your request. The Plan says there is a maximum allowance of $200 per quarter. The Plan says that the maximum allowance has been exceeded.

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 maximum allowance has been exceeded.

TOTAL:
$800

The Evidence of Coverage clearly states that after the plan pays benefits for comprehensive dental services, you are responsible for the remaining costs. Therefore, we decided that the Plan does not have to pay for the additional 15 minutes of intravenous (IV) sedation (D9243) provided on December 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.

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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no
documentation provided necessitating admission to a LTACH. 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. There are no services available at the LTACH that the
enrollee requires that are not available at the health care setting being offered by the health plan. The requested
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of
the enrollee.

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 LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a Barostim Neo system.

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 that the services are not medically necessary.

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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has NYHA class III heart failure with an ejection fraction of 25 to 30 percent. He has failed both beta blocker and ARB pharmacotherapy. He has severe dyspnea on exertion and fatigue. The Barostim Neo system is reasonable and medically necessary for the enrollee 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a Barostim Neo system.

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.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from LTACH care. The Plan denied your request. The Plan says the enrollee can receive adequate care in the current facility.

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 was admitted for sepsis from osteomyelitis. He continues to receive acute care services that have not been denied. The record does not indicate that the enrollee requires services that he is not currently receiving that only the LTACH would be able to provide. The elements of the coverage criteria 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 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.