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

We decided that the Plan does not have to pre-approve an artificial larynx (L8500).
You asked the Plan to pre-approve an artificial larynx. You say that the records provided support the need for an artificial larynx. The Plan denied your request. The Plan says this item is not a covered benefit.
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 artificial larynx. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is documented that you use esophageal speech and haven't shown up to many speech pathology visits. Your doctor documented that you should be able to manage your voice and swallow issues on your own at this point. Imaging has shown no evidence of recurrence or metastatic disease. The available documentation in the case file does not demonstrate that an artificial larynx (L8500) is medically reasonable and necessary for you 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 an artificial larynx have not been met. Therefore, we decided that the Plan does not have to pre-approve an artificial larynx (L8500).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom 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 the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered for beneficiaries who test insulin levels at least three times per day who meet specific criteria. We looked at the file and Medicare rules. The file shows that you test your insulin levels twice per day. 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 Dexcom continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.
You asked the Plan to pre-approve Gelsyn-3. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Gelsyn-3. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found you are noted to have knee pain. There is no evidence that you are allergic to or intolerant of
the plan's preferred brands of hyaluronic acid injection. There is no evidence that you have tried and not
responded to these other forms of hyaluronic acid injections. Therefore, you do not meet criteria for the
requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gelsyn-3.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is 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 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 required minimal assistance/contact guard assistance with transfers. The enrollee required minimal assistance with walking 70-80 feet times two with a front rolling walker. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status requires an 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: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a sleep study.
You asked the Plan to pre-approve sleep study. You say that the enrollee never showed up for a previously authorized sleep study, so you are requesting it again. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the enrollee denies any daytime drowsiness, napping, falling asleep, or interference with driving.
The Plan follows Medicare rules. Medicare rules say that sleep studies are covered for the evaluation of symptoms or complaints of certain conditions, including sleep apnea. 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 sleep study. Our reviewer says that the enrollee meets the Medicare criteria for the requested sleep study. Our physician reviewer found the enrollee has been referred for a sleep study for snoring. She reported no stop-breathing events but does report the occasional gasping or choking during the night. She reported sleep maintenance issues and that she gets 5 fragmented hours of sleep at night. She denied morning headaches or falling asleep during the day. Although it is likely that the enrollee's allergic rhinitis may be contributing to her snoring, due to the fact that she reported gasping or choking it is highly suspicious of sleep apnea and she would be at high risk of this as well. It is medically reasonable and necessary to undergo a sleep study in this case, but also while treating her allergic rhinitis to rule this out as a cause.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sleep study have been met. Therefore, we decided that the Plan has to pre-approve a sleep study.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) of the brain.
You asked the Plan to pre-approve the MRA of the brain. You say that the MRA is needed to rule out vascular issues causing neurological symptoms. The Plan denied your request. The Plan says the enrollee does not have signs or symptoms which support this imaging.
The Plan follows Medicare rules. Medicare rules say that MRA of the head/neck are covered when reasonable and necessary as defined 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 the MRA of the brain. Our reviewer says that the documentation does not support that the requested MRA is reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of Parkinson's Disease. She was noted to have some small vessel ischemic gliotic disease on MRI of the brain. However, she had no signs or symptoms of a condition for which surgery is anticipated (e.g. aneurysm, AVM, tumor). There is otherwise no indication within the records provided for review that the member is suspected of having a medical condition for which MRA would be of clinical utility in diagnosis and management. In as much, it cannot be said that the requested scan would be 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 the MRA of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) of the brain.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee surgery.
You asked the Plan to pre-approve knee surgery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 knee surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has degenerative joint disease of the knee. There are no weight bearing films. An MRI shows degenerative joint disease and not a single cartilage lesion. The documentation does not support that criteria is met for the specific procedure requested. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve knee surgery.
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 SNF admission. You say that you feel that a SNF is necessary. The Plan denied your request. The Plan says you are receiving appropriate care in the IRF setting at this time, and there is no need for discharge to SNF.
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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted with a thalamic stroke on 7/25/2020. He was transferred to an IRF for rehab on 7/28/2020. He returned to acute on 7/30/20 after being found unresponsive to the IRF. The patient had a second episode of unresponsiveness during 7/30-8/4 but was negative for seizure activity and neurology feels hypersomnolence is due to thalamic involvement. He was readmitted to the IRF on 8/5 where he remains. The patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. He does not have complex wound care or other ongoing SNF level SN need. His functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF.
He does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on 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 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve insertion of new or replacement of permanent pacemaker.

You asked the Plan to pre-approve insertion of new or replacement of permanent pacemaker. 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 insertion of new or replacement of permanent pacemaker is 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 insertion of new or replacement of permanent pacemaker. Our reviewer says that the documentation supports that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee a history of paroxysmal atrial fibrillation and hypertension (treated with metoprolol) as well as vasovagal syncope. Based on the records the enrollee has unexplained sudden falls with questionable loss of consciousness in conjunction with multiple symptomatic 3-4 second pauses on ambulatory monitoring. In addition, metoprolol is medically necessary for treatment of the enrollee's hypertension. In this circumstance pacemaker placement is reasonable, appropriate and considered standard accepted practice in the medical community. Coverage criteria are met since one covered indication includes "Documented non-reversible symptomatic bradycardia due to sinus node dysfunction".

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of new or replacement of permanent pacemaker have been met. Therefore, we decided that the Plan has to pre-approve insertion of new or replacement of permanent pacemaker. 

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: 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 SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee required assistance with walking 30 feet with a front wheeled walker. The enrollee required moderate assistance with bed mobility. The enrollee required stand-by assistance/supervision with upper body dressing. The enrollee was independent for grooming. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF 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 SNF 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: 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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is 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 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 required minimal assistance with bed mobility. The enrollee required contact guard assistance with transfers and walking 132 feet. The enrollee required maximum assistance for lower body dressing. The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation supports that the enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee replacement surgery to be provided by an out of network (OON) facility.
You asked the Plan to pre-approve the OON knee replacement surgery. You say that you feel that this is necessary. The Plan denied your request. The Plan says there are network providers able to provide this surgery once your infection has resolved.
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 knee replacement surgery to be provided by an out of network (OON) facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and extraction of four teeth with an oral surgeon.
You asked the Plan to pre-approve a consultation and extraction of four teeth with an oral surgeon. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 consultation and extraction of four teeth with an oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omega-3 for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee needs this to help lower her cholesterol. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Omega-3 for the enrollee.
Benefits for this drug 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Duloxetine for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Duloxetine for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.