Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed and accessories for the
enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the provider notes do not show that this bed is needed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
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 services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the records do not
indicate that frequent and/or immediate changes in body position are required. There is no documented need for
special attachments that cannot be fixed to an ordinary bed. A hospital bed is therefore not 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a semi-electric hospital bed and accessories for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl for the enrollee.

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 self-administered drugs are not covered.

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 Fentanyl for the enrollee. 

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 requestto pre-approve IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 14, 2020 with a urinary tract infection. The physical therapy note dated January 18, 2020 states she needs minimal assist to walk 15 feet with a rolling walker and cannot tolerate three hours of therapy. She has no complex needs that require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF carehave not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 10, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you should not owe a copayment for lab services because you had an office visit on the same day. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for lab services. You received laboratory services on September 10, 2019. The record shows that you had an office visit on September 11, 2019. Since an office visit did not take place on September 10, 2019, you are responsible to pay the $10 copayment for laboratory services. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services provided on September 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an arthroplasty (27446).
You asked the Plan to pre-approve an arthroplasty. You say that this is medically necessary. The Plan denied
your request. The Plan says the enrollee's BMI is too high for this procedure.
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 an arthroplasty. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee's BMI is too high. Weight loss is needed for this service to be considered 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 an arthroplasty have not been met. Therefore, we decided that the Plan does not
have to pre-approve an arthroplasty (27446).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral formula for the enrollee.
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 services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that enteral formula is covered when specific 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is noted to have had a stroke resulting in hemiplegia. There is no evidence that the enrollee has dysphagia, gastric dysmotility, malabsorption or a feeding tube. The requested nutritional supplements are not covered as medically necessary, as the enrollee will not receive enteral formula via a feeding tube. 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 enteral formula for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for six visits an out-of-network
provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there are in-network providers available.
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 pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral for six visits with an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee is not safe to return home. The Plan denied your request. The Plan says the enrollee's functional capability will not likely be significantly reduced if SNF services are not done.
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 SNF services. Our physician reviewer found that from a nursing perspective, the enrollee has stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at supervision to minimal assist for functional mobility. She requires varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you are weak and deconditioned. The Plan
denied your request. The Plan says you are medically stable, with no skilled nursing needs.
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 SNF services. Our physician reviewer
found that from a nursing perspective, you have stable vital signs. There are no identifiable skilled nursing
service needs. Regarding rehab services, you require varying assist with activities of daily living. Although
there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a
daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says that they did not receive documentation or medical records supporting the medical necessity for a step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary for the enrollee in this case. The provided medical records do not indicate that the enrollee has tried and failed Retacrit or that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Aranesp 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower back injections 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 no new clinical documentation has been provided to determine the medical necessity of these procedures.
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 injection. Our reviewer says that the requested injections are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that in regards to all of the requested procedures, there is no documentation that this enrollee's pain has failed to respond to an adequate trial of conservative treatment including physical therapy, chiropractic therapy, or a physician-supervised home exercise program in addition to oral pain medications including NSAIDs. Furthermore, it is not appropriate or a standard of care to perform multiple interventional pain management procedures in the same body region on the same date of service as this may lead to an improper diagnosis as to the actual pain generator. It is excessive, and exposes the enrollee to unnecessary risk. Therefore, the requested lumbar facet injection, lumbar medial branch nerve radiofrequency ablation, and lumbar transforaminal epidural steroid injection are not 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve lower back injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS implant for the enrollee.
You asked the Plan to pre-approve the implant. 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. 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 implant. Our reviewer says that the
requested implant is not considered medically reasonable and necessary in this case. Our physician reviewer
found in this circumstance therapy change based on data obtained from a CardioMEMs device has been
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.
Moreover, concerns have been raised about potential bias in this trial calling into question the results.
Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and
not recommended in current guidelines for the treatment of heart failure. This device should still be considered
experimental and investigational.
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 implant have not been met. Therefore, we decided that the Plan does not
have to pre-approve the CardioMEMS implant for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee injections to be provided by an out of network provider.
You asked the Plan to pre-approve the knee injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The plan states there are equally qualified in-network providers that can provide the services you are requesting.
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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the knee injections to be provided by an out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 are no apparent nursing needs that cannot be provided in the home setting.
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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency ambulance services (A0429) and ground mileage (A0425) provided  January 17, 2019.
You asked the Plan to pay for the ambulance services.. You say that that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this date of service is after the date of the enrollee's death.
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary]. Per the records the enrollee's date of death is January 9, 2019. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services. have not been met. Therefore, we decided that the Plan does not have to pay for emergency ambulance services (A0429) and ground mileage (A0425) provided January 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to gain full physical function and mobility. The Plan denied your request. The Plan says there is no medical complexity that supports the need for an inpatient rehab physician 3 times a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee's current level of function is ambulating 280 feet with a wheeled walker with standby assist, independent with bed mobility, transferring with supervision, supervision with bed mobility, contact guard assist with dressing, modified independent/contac guard assist with bathing, contact guard assist with light home management tasks. The enrollee is currently medically stable. There is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While she may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (endodontic therapy) for tooth 13.
You asked the Plan to pre-approve these services. You say that your tooth has worsened and needs a root canal. The Plan denied your request. The Plan says the services are not a covered benefit.
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 root canal (endodontic therapy) for tooth 13.