Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee's 
needs can be met at a custodial 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 SNF services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. There 
are no identifiable skilled nursing service needs. Regarding rehab services, he was at a standby assist level with 
functional mobility. He required varying assist with activities of daily living. There are no identifiable therapy 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. He does not 
meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on December 4, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were there for screening 
purposes. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 
copayment for outpatient diagnostic tests/ultrasound.  
 
You have been asked to pay a $55 copayment for an ultrasound. The correct copayment has been applied to the 
ultrasound that was provided. An ultrasound falls within the outpatient diagnostic tests/ultrasound benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on December 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that this is medically necessary. 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 stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545. 
 
You asked the Plan to pre-approve the compression stockings. You say please see recommendation for sleeve. 
The Plan denied your request. The Plan says the records do not show that the enrollee has any ulcer and/or 
open wound, therefore this does not meet the definition of a surgical dressing. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6545.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital admission. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee requires an inpatient 
stay for a total shoulder arthroplasty. The Plan denied your request. The Plan says coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient stay are met in this case. 
Our physician reviewer found the patient's medical history did not suggest that there would be likely 
complication or requirement for specialized aftercare warranting prolonged hospitalization. The records 
provided do not suggest the patient would require hospital services that would likely cross 2 midnights for this 
surgery. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an acute inpatient hospital admission.
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 the enrollee has severe and worsening lymphedema. The Plan denied your request. The Plan says the services are not covered.

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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pegfilgrastim. 
 
You asked the Plan to pre-approve Pegfilgrastim. You say that the requested Pegfilgrastim is medically 
necessary. The Plan denied your request. The Plan says the requested Pegfilgrastim is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Pegfilgrastim. Our reviewer says that 
the requested Pegfilgrastim is not medically necessary. Our physician reviewer found the enrollee is with a 
diagnosis of myelodysplastic syndrome. The requested use of Pegfilgrastim is not FDA-approved for the 
enrollee's diagnosis. The use of Pegfilgrastim for the enrollee's condition is not supported by one of the major 
drug compendia or by clinical research that appears in a CMS-approved medical journal, not without recurrent 
or life-threatening infection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pegfilgrastim have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Pegfilgrastim.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is not ready to be out of the 
hospital. The Plan denied your request. The Plan says the enrollee still has acute medical needs that require the 
oversight by surgical services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that you are being treated for necrotizing pancreatitis. Your vital signs are stable. You are 
otherwise hemodynamically stable. You are receiving appropriate care at the present acute care hospital. You 
do not require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. There are no services available at the LTACH that are not available at the health care setting 
being offered by the health plan. The requested LTACH services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 your life is in danger without the requested SNF care. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care provided to the enrollee.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found at the time of admission, the enrollee required
skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing
needs. The enrollee did not require any skilled nursing or rehab services on a daily basis.
The enrollee was not expected to make measurable gains within a reasonable and predictable period of time or
require skilled therapy to prevent deterioration with mobility or ADLs. The enrollee did not require skilled
therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not
require any skilled services on an inpatient basis, at a SNF level of care. The enrollee did
not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee
received skilled care and improved, however their function had plateaued and the enrollee did
not require any further inpatient skilled rehab services. The enrollee's function was at or near their prior level
of function and the enrollee could be discharged to a lower level of care for further services. The enrollee
required custodial services. The denial for further inpatient skilled care 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve continuation of SNF care provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Euflexa injection.
You asked the Plan to pay for Euflexa injection. 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 follows Medicare rules. Medicare rules say that Euflexxa injections are 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 pay for Euflexa injection. Our reviewer says that the documentation does not support that the requested services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee pain and sacroiliac pain. The enrollee has undergone radiofrequency ablation of the genicular nerves for pain control. The documentation does not include a physical examination or x-ray evidence establishing the diagnosis of osteoarthritis. therefore, the enrollee does not meet 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 Euflexa injection have not been met. Therefore, we decided that the Plan does not have to pay for Euflexa injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader system for the enrollee.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says the rules require a minimum of three injections of insulin daily that are adjusted each time or use of an insulin pump.

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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has been using insulin multiple times (3 or more) a day but her treatment does not require frequent adjustment on the basis of testing results.

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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader system for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Adempas tablets.
You asked the Plan to pre-approve Adempas tablets. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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 tablets.
Benefits for Adempas tablets 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoscopic decompression of spinal cord (62380). 
 
You asked the Plan to pre-approve endoscopic decompression of spinal cord. You say that this service is 
medically necessary. The Plan denied your request. The Plan says there is not enough evidence to support that 
the specified surgery is medically helpful for the enrollee's condition. 
 
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 endoscopic decompression of spinal 
cord. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found percutaneous spinal decompression remains experimental. 
More research is needed to define complications, outcomes, and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endoscopic decompression of spinal cord have not been met. Therefore, we 
decided that the Plan does not have to pre-approve endoscopic decompression of spinal cord (62380).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two impressions and custom preparations for an oral 
surgical splint (21085 x2), two face bone grafts (21210 x2), two lower jaw bone grafts (21215 x2), and 
panoramic x-ray of the jaws (70355). 
 
You asked the Plan to pre-approve the impression and custom preparation for an oral surgical splint, bone 
grafts, and panoramic x-ray. You say that these procedures are not for routine dental care. The Plan denied your 
request. The Plan says these services are not covered under Medicare. 
 
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 two 
impressions and custom preparations for an oral surgical splint (21085 x2), two face bone grafts (21210 x2), 
two lower jaw bone grafts (21215 x2), and panoramic x-ray of the jaws (70355).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like this claim reprocessed and 
approved for these services to be provided by an out-of-network provider. 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 
an office visit to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage.

You asked the Plan to pre-approve continued SNF coverage. 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. 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 continued SNF coverage. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found you required stand-by
assistance to walk 80 feet then 70 feet using a front wheeled walker. You required contact guard/minimal
assistance to lie down. The documentation does not support that you require daily skilled services to establish a
maintenance program or to prevent deterioration of your condition. Your 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 continued SNF coverage have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) coverage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre continuous glucose monitor and sensors.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements have not all been met.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee is not on insulin. The elements of the local coverage determination are not satisfied. The requested service cannot be recommended. 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 the Freestyle Libre continuous glucose monitor and sensors.