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 this is necessary for you to return to being independent. The Plan denied your request. The Plan says you can be treated 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. Our physician reviewer found the records show that you were admitted for weakness and decreased appetite. Your medical problems are now stable, and there are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. 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 the insertion of a Vertiflex device (22869).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device remains experimental. More research is needed to show it is safe and effective. 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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The records show that you are pre-diabetic and not treated with insulin. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that this is for the safety and health of the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for the beneficiary, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an implantable loop recorder.
You asked the Plan to pre-approve an implantable loop recorder. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that implantable loop recorder is only covered for certain indications. 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 implantable loop recorder. Our reviewer says that the documentation does support that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has a history of palpitations and 14 day event monitor showing paroxysmal atrial tachycardia and a possible episode of atrial fibrillation (AF). The enrollee has documented rapid atrial tachycardia but no clear evidence of paroxysmal atrial fibrillation (PAF) though she has been started on anticoagulation. The enrollee is being evaluated by a cardiac electrophysiology specialist who is not convinced of the PAF seen on the ambulatory monitor. However, the enrollee's CHA2DS2VASc score is elevated and the enrollee would benefit from anticoagulation if PAF is documented. Given the atrial arrhythmias (which could predispose to PAF) and the concern for possible PAF on the prior ambulatory monitor, prolonged implantable loop recorder (ILR) monitoring is a reasonable clinical strategy if discontinuation of anticoagulation is going to be done. Documentation of PAF on the implantable loop recorder would have a significant effect on the medical management of this enrollee and this may require prolonged electrocardiogram monitoring. In this instance, even in the absence of syncope, this meets the trans-telephonic monitoring criteria of the NCD guideline (implantable loop recorder remote transmissions) as noted below, since detection of PAF in this instance would lead to a major change in medical therapy (i.e. re-institution of lifelong anticoagulation therapy +/- suppression of PAF). This would be a medically necessary and reasonable use of the ILR technology. Therefore, the enrollee meets criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an implantable loop recorder have been met. Therefore, we decided that the Plan has to pre-approve an implantable loop recorder.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you are appealing this denial. The Plan denied your request. The Plan says the provider is out-of-network.
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 the office visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and debridement in the presence of inflammation or mucositis of a single implant (D6081 x 8).
You asked the Plan to pre-approve the dental service. You say that you had to have implants done. You say that you need this cleaning. You also say that it is not fair that you cannot get the cleaning that you need. The Plan denied your request. The Plan says scaling and debridement in the presence of inflammation or mucositis of a single implant is not listed as a covered service.
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 scaling and debridement in the presence of inflammation or mucositis of a single implant (D6081 x 8).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this is necessary for the enrollee to continue to manage his diabetes with only diet and oral medication. The Plan denied your request. The Plan says this is only covered for enrollees treated with insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide the requested brand of HFCWOD from an out-of-network provider.
You asked the Plan to provide a brand of HFCWOD. You say that this system was specifically requested by the enrollee's doctor. The Plan denied your request. The Plan says an HFCWO device is medically necessary but the out-of-network brand of HFCWO is not necessary.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 provide this HFCWOD. Our reviewer says that the requested device, to be provided by an out of network vendor, is considered not medically necessary. Our physician reviewer found an HFCWO can be provided in-network, and this apparently has been approved. The advantages of the requested device, as stated by the vendor, are not considered significant enough to make a clinical difference, and there are no clinical studies to support the benefits of this device over other brands. The denial is upheld. 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 HFCWOD have not been met. Therefore, we decided that the Plan does not have to provide this brand specific HFCWOD from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a retreatment of previous root canal therapy (D3348).
You asked the Plan to pay for the retreatment of previous root canal therapy. You say that you would like this service to be approved for coverage. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 pay for a retreatment of previous root canal therapy (D3348).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gammagard injections (J1569).
You asked the Plan to pre-approve Gammagard injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the use of intravenous immune globulin (IVIG) should be reserved for patients with serious defects of antibody function. 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 Gammagard injections. Our reviewer says that the Gammagard injections are not medically necessary. Our physician reviewer found the role of IVIG therapy in the management of sero-negative autoimmune epilepsy secondary to possible sero-negative VGKC encephalitis has not been established. The use of IVIG in this setting cannot be recommended 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 Gammagard injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Gammagard injections (J1569).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain (70551).
You asked the Plan to pre-approve an MRI. You say that the enrollee is experiencing memory decline. The Plan denied your request. The Plan says that the enrollee has recently had a normal MRI.
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 an MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found it is standard to perform an imaging study to rule out any structural process as a cause of cognitive impairments. In this case, the enrollee has a recent onset of cognitive impairments, meaning it is clinically reasonable for the enrollee to receive the requested MRI. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain (70551).
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) physical therapy (PT) visits.

You asked the Plan to pre-approve the additional ten (10) PT visits. You say that The Plan denied your request. The Plan says based on the clinical information the PT is not medically necessary.

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 the additional ten (10) 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 safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. 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 the additional ten (10) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you no longer require skilled services and the continuation of SNF care is not medically necessary.

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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the shoulder sling provided on January 14, 2021.

You asked the Plan to waive the coinsurance for the shoulder sling. You say that you should not be charged for the sling because you do not have the sling. You say you did not know you were to take the sling. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 20% coinsurance for prosthetic devices and medical supplies. 

You have been asked to pay $18.88 which is 20% of the allowed amount for the shoulder sling. The allowed amount is $94.40. ($94.40 x 20% = $18.88). The shoulder sling falls within the "Prosthetic devices and related 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 coinsurance for the shoulder sling provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this is medically necessary. The Plan denied your request. The Plan says this is only covered if you are treated with insulin.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee's medical records indicate that the enrollee does not have current skilled nursing needs and the current non-skilled nursing needs of surgical wound care can be managed at a lower level of care, such as home with home health care services to continue making progress towards your goals. The enrollee does not meet skilled criteria for the subacute rehabilitation level of care.

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 from a nursing perspective; the enrollee received oral medications. The enrollee had stable vital signs. She was treated for pain with effect. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the acute hospital. The enrollee was at a modified independent to stand by assist level for functional mobility including gait to 1250 feet with a walker. The enrollee required varying assist with ADLs. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.