Persius/hicric huggingface dataset:
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 it is felt that acute rehabilitation is needed for this enrollee. The Plan denied your request. The Plan says the enrollee does not require frequent physician oversight or acute rehab nursing services in the hospital 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 enrollee is in the home being treated for shoulder pain. She was referred for an admission to an IRF as she is having difficulty with activities of daily living (ADLs).
The enrollee has been walking with two canes and using a pump for management of lymphedema. Documentation does not support the need for therapy program consisting of at least 3 hours of therapy per day at least 5 days per week for shoulder pain. While she may benefit from PT, and OT, but there is no evidence of need for an intensive therapy program with frequent physician oversight and an interdisciplinary approach to rehabilitation care. IRF admission is not medically necessary based on lack of medical complexity and no identified skilled rehab nursing needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #2.

You asked the Plan to pre-approve the crown. You say that since you received the last crown you have been getting infections and you were advised that you need to have the crown repaired or replaced. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you received this service less than 60 months ago.

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, crowns are limited to 1 per tooth per 60 months. The record shows that you received a crown (D2751) on tooth #2 on October 22, 2019 and your crowns benefit for tooth #2 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildups (D2950 x2).

You asked the Plan to pre-approve core buildups. You say that you want the Plan to cover the services. The Plan denied your request. The Plan says the services at issue are not covered benefits.

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 core buildups (D2950 x2).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Adempas.
You asked the Plan to pre-approve Adempas. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under your medical benefit.
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 Adempas.
Benefits for Adempas 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 skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not require daily skilled services on an inpatient basis.

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 SNF services. Our physician reviewer found that you do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. You do not require services 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee and billed under codes 81401, 81403, 81404, 81405, 81406, 81185, and 81479.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11; therefore, the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to an issue with the POS codes reported. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee and billed under codes for 81401, 81403, 81404, 81405, 81406, 81185, and 81479.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a powered pressure reducing air mattress 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 that there needs to be a physician's order.
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that based on the medical records provided there is documentation that the enrollee has a large stage IV pressure ulcer on the trunk or pelvis; records from 05/12/2021 document a stage IV sacral pressure ulcer 2.7x5x1.3 cm in dimension. 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 been met. Therefore, we decided that the Plan has to pre-approve a powered pressure reducing air mattress for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve routine transportation. You say that allowing transportation to this provider will save costs down the road. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation mileage is correct, because routine transportation beyond 50 miles per one-way trip is not covered by the Plan.
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 routine transportation up to 50 miles of driving distance per one-way trip.
We looked at your request, the records in the case file, and the rules. Transportation to this destination would exceed 50 miles per one-way trip. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
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 SNF services. The Plan denied your request. The Plan says you do not need skilled nursing or therapy on a daily basis.
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 SNF services. Our physician reviewer found that you are at an independent level for standing up and sitting down, supervision for toilet transfers, and independent with grooming. You do not have documented skilled nursing or therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. At this point, your care needs are custodial. 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) service
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical implant placement (D6010) and deep sedation (D9222 and D9223).

You asked the Plan to pre-approve the surgical implant placement (D6010) and deep sedation (D9222 and D9223). You say that the infection is getting worse and the doctor says this is medically necessary. You say that you need this expedited or you have to switch plans to get this covered elsewhere. The Plan denied your request. The Plan says the services are not covered benefits.

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 the surgical implant placement (D6010) and deep sedation (D9222 and D9223).
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 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 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 medically necessary. Our physician reviewer found you were admitted to the hospital with weakness and a build up of blood (hematoma). You are now medically stable with 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. While the documentation does support a
need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 for the enrollee.
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 the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a fall and non-surgical management of a small intracranial hemorrhage. She was discharged home on August 25, 2021. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says based on the current needs, care at home is recommended.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing or 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 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) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you suffer from intense pain in the soles of her feet. Your doctor told you that you need an operation, but you don't want to. The compression stockings were recommended by your doctor. The Plan denied your request. The Plan says this item is not covered benefits.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve pain management services. You say that this would be for a second opinion. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 pain management services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated oral appliance (E0486).
You asked the Plan to pre-approve a custom oral appliance. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says rules for coverage of a custom oral appliance have not been met.
The Plan must follow Medicare rules. Medicare rules say that that a custom fabricated mandibular advancement oral appliance used to treat OSA is covered when the criteria in the Medicare rules section 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 a custom oral appliance. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that you have sleep apnea. The available sleep study is from 2013 and predates the visit with the treating physician in this case. The available medical records are insufficient to determine whether the coverage criteria are 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 a custom oral appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated oral appliance (E0486).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 28 and 31, and pontics (D6245) for teeth # 29 and 30.
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontics are not listed as covered services either.
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 retainer crowns and pontics are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 28 and 31, and pontics (D6245) for teeth # 29 and 30.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral three-level facet joint injection.
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 denial was appropriate given the clinical scenario.
The Plan must follow Medicare rules. The rules say that one to two levels, either unilateral or bilateral, are allowed per session per spine region. 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 considered medically reasonable and necessary in this case. Our physician reviewer found the provided record does not include documentation of a physical examination of the lumbar spine to assess facet pathology. The submitted record does not describe unique circumstances with enough documentation of medical necessity to support simultaneous treatment of more than two levels. The elements of the coverage rule are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral three-level facet joint injection.