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

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this request is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 enrollee meets IRF admission criteria under CMS guidelines. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive care in another setting.

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 back pain, weakness and a fall. He was treated for a urinary tract infection and had lumbar epidural steroid injection. The enrollee's medical conditions 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgery provided on November 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient surgery provided on November 25, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozurdex (J7312).

You asked the Plan to pre-approve Ozurdex. The Plan denied your request. The Plan says the off-label use of
this drug for the enrollee's condition is not medically accepted per Medicare rules, and is not covered based on
available information.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Ozurdex. Our reviewer says that
treatment with Ozurdex implant is not medically necessary in this case. Our physician reviewer found although
Dexamethasone implant is safe and effective for some macular diseases, in this case it would not be
recommended. Our reviewer found that there is evidence in the medical literature that adjunctive treatment of
intravitreal Lucentis with Dexamethasone implant for macular degeneration does not improve outcomes for the
disease and subjects the enrollee to undue risk of side effects from the steroid. Our physician reviewer also
found that the Plan's denial of coverage and argument is valid.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ozurdex have not been met. Therefore, we decided that the Plan does not have
to pre-approve Ozurdex (J7312).
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 cervical fusion. Medical
conditions 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. The enrollee does require physical and occupational
therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a capsule endoscopy (91112).
You asked the Plan to pre-approve a capsule endoscopy. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary because it is experimental/investigational.
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 capsule endoscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Wireless Motility Capsule (SmartPill, WMC) is FDA approved for evaluation of gastric emptying in gastroparesis, colonic transit in constipation, and evaluation of generalized dysmotility. However, WMC has not been widely accepted as standard of care in clinical practice outside of tertiary care specialty centers and is not more readily available than gastric motility or colon transit testing. 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 capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a capsule endoscopy (91112).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) brain, including brain stem (70551).

You asked the Plan to pre-approve the MRI. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records provided does not support medical necessity of the requested service.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee was seen in clinic and complained of memory loss. Neurologic examination was normal and mental status examination noted to be at baseline. Workup was ordered, including MRI but no results are available. The case file indicated that the provider did not notice any memory impairment upon examination and did not do other testing due to time constraints because of other urgent complaints. The documentation does not support the medical necessity or reasonableness, as defined by Medicare rules, of the requested test.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) brain, including brain stem (70551).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on November 4, 2020.
You asked the Plan to pay for the cardiovascular screening. You say that you would like reconsideration because these services were rendered in good faith to the member. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the cardiovascular screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the record does not include sufficient clinical information to determine if this testing was medically necessary or why this testing was ordered. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit (99203) you received on December 23, 2020.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic office visit (99203) you received on December 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc (J7327).

You asked the Plan to pre-approve Monovisc. The Plan denied your request. The Plan says Monovisc is not
medically necessary.

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 Monovisc. Our reviewer says that
criteria has not been met for a repeat injection of Monovisc. Our physician reviewer found the enrollee has
already had a previous knee injection with Monovisc. The results of the injection are not documented. Our
reviewer also found that it is unknown how much functional improvement was achieved with the first
Monovisc injection.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve Monovisc (J7327).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Albuterol Sulfate HFA.
You asked the Plan to pre-approve Albuterol Sulfate HFA. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says Albuterol Sulfate HFA is not covered under the
enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Albuterol Sulfate HFA.
Benefits for Albuterol Sulfate HFA 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: 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 admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with collapsed vertebra, edema and congestive heart failure. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy. By the dates in question, the enrollee was non-ambulatory and required maximal assist with mobility. The enrollee required varying assist with activities of daily living.

There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This 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 admission to a SNF 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: 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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pelvic fracture after a fall.
Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi electric hospital bed (E0261).
You asked the Plan to pre-approve a semi electric hospital. You say that the hospital bed is medically necessary, and you are appealing the denial. The Plan denied your request. The Plan says the requested semi electric hospital bed is not medically necessary, and the enrollee's needs can be met with a standard hospital bed.
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 a semi electric hospital. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal objective treating medical provider notes indicating a need for this bed. The documentation does not clearly reveal that enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for this 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 a semi electric hospital have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi electric hospital bed (E0261).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine eye exam provided on September 22, 2020.

You asked the Plan to pay for the routine eye exam. The Plan denied your request. The Plan says that the
routine eye exam benefit was already exhausted for 2020. The enrollee previously received a routine eye exam
on March 4, 2020.

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 once per calendar year.

We looked at the file and the Plan's rules. The file shows that the enrollee's routine eye exam benefit was
exhausted on March 4, 2020. Based on this information, we decided that the Plan's rules for coverage of the
routine eye exam have not been met. Therefore, we decided that the Plan does not have to pay for a routine eye
exam provided on September 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee is currently waiting in the hospital to be sent to the SNF. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee can receive the care needed in another setting.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee was treated for a post-operative hematoma in her right thigh and was treated for pain. The enrollee received physical therapy, speech therapy, and occupational therapy in the acute hospital. The enrollee was at a stand-by-assist to minimal assist level with functional mobility, including gait to 300 feet with a rolling walker. The enrollee required varying assist with activities of daily living. The enrollee tolerated a regular diet and thin liquids. There are no identifiable skilled nursing service needs. While there are identifiable skilled therapy service needs, they are not required 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.