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

We decided that the Plan does not have to pre-approve spinal surgery.
You asked the Plan to pre-approve spinal surgery. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Superion spacer remains experimental for use in spinal surgery. More research is needed to show safety and efficacy of the device. Open laminectomy is the gold standard procedure for spinal stenosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an out-of-network provider.
You asked the Plan to pre-approve outpatient mental health services. You say that you are in recovery and you have a solid working relationship with the counselor. The Plan denied your request. The Plan says the provider is not a network provider or a Medicare qualified provider.
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 outpatient mental health services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a over-bed table.
You asked the Plan to pre-approve the requested over-bed table. You say that you need this because you are not able to hold a bowl due to tremors and are too weak to go to the regular table. The Plan denied your request. The Plan says this is not a medical item and cannot be covered.
The Plan must follow Medicare rules. Medicare rules say that over-bed tables are considered convenience items and cannot be covered by Medicare. Although this item may be appropriate for you, neither Medicare nor the Plan provides coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a over-bed table.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a forehead thermometer.
You asked the Plan to pre-approve a forehead thermometer. You say that you would like this so your family can come visit. The Plan denied your request. The Plan says that this is not covered under Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a forehead thermometer.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage per one-way trip.
You asked the Plan to pre-approve additional mileage. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee's transportation benefit is limited to 30 miles per one-way trip.
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 a maximum of 12 one-way transportation trips per year, not to exceed 30 miles per trip. We looked at the file, the Plan's contract and Medicare rules. The file shows that you are asking for additional mileage per one-way trip for the enrollee to get to her destination. The Plan contract clearly limits each trip to 30 miles. Therefore, we decided that the Plan does not have to pre-approve additional mileage per one-way trip.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 3, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 3, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy.

You asked the Plan to pre-approve Ubrelvy. The Plan denied your request. The Plan says Ubrelvy to be taken at home is not covered under the Part B 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 Ubrelvy.

Benefits for Ubrelvy 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower limb prosthesis.
You asked the Plan to pre-approve a lower limb prosthesis. You say that you need this immediately to regain your ability to walk, go upstairs and run. The Plan denied your request. The Plan says that the request for entire replacement K3 prosthesis exceeds your need and cannot be covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a lower limb prosthesis. Our reviewer says that the requested lower limb prosthesis is not considered medically reasonable and necessary in this case. The requested items exceed your medical need as the documentation does not include objective physician progress note documentation supporting that you are a level K3 ambulator and indicating a need for an entirely new K3 foot. The documentation indicates inconsistencies between the two different prosthetist notes on the patient's functional level/ability with his prosthesis. Furthermore, the most recent prosthetist note, "initial evaluation" is dated on 2/4/21 and states the patient last visited a physician on 2/9/21 which is 5 days after the evaluation is taken. The note also is indicates the patient's date of amputation is 2/26/21 which is after the date of the initial evaluation. Given these inconsistencies, as well as no supporting physician progress notes supporting the need for a new K3 foot the entire request is not medically necessary. Our physician reviewer found that your condition does not meet criteria for coverage of the requested lower limb prosthesis. 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 lower limb prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower limb prosthesis.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax (71260).
You asked the Plan to pre-approve a CT scan. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not necessary at this time.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that the requested follow-up CT scan of the chest is considered reasonable and necessary. Our physician reviewer found the enrollee underwent a lung cancer screening in July 2020. Multiple nodules were identified, and the imaging was classified as suspicious. A follow-up chest CT on November 11, 2020 raised questions about enlargement of at least one of the nodules and identified a new nodule. However, the difference in technique (low-dose vs dedicated) affected the precision of the size comparisons. The radiologist recommended follow-up in another 3 months. Given the uncertainty about whether there are enlarging nodules and noting that one of the nodules is larger than 1.0 cm in one dimension, a follow-up CT scan now is considered 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 a CT scan have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax (71260).
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tubal ligation (sterilization).

You asked the Plan to pre-approve sterilization. You say that the enrollee chooses to avoid a pregnancy. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because tubal ligation is not covered by Medicare for elective sterilization.

The Plan must follow Medicare rules. Medicare rules say that tubal ligation is not covered for elective sterilization. 

We looked at the file and Medicare rules. This procedure is being requested for elective sterilization. Based on this information, we decided that Medicare rules for coverage of sterilization have not been met. Therefore, we decided that the Plan does not have to pre-approve tubal ligation (sterilization).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for sepsis. Her 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Additionally, 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.
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 an 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 semi-precision attachment abutments (D6052) for teeth # 22 and 27.
You asked the Plan to pre-approve the dental services. You say that the enrollee is going to have teeth # 22 and 27 extracted. You say that the enrollee will need an implant supported removeable denture for edentulous arch which needs to be attached to teeth # 22 and 27 otherwise it is not possible. You also say that these services will improve the enrollee's quality of life. The Plan denied your request. The Plan says semi-precision attachment abutments are not listed as covered services.
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 semi-precision attachment abutments (D6052) for teeth # 22 and 27.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar spinal fusion.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee underwent surgery in August of 2020. The criteria for coverage have not been met. It has not been a year since the prior surgery and there is no clear radiographic evidence of pseudoarthrosis. The enrollee has also not exhausted available conservative treatment measures. The requested surgery is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spinal fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the knee.
You asked the Plan to pre-approve the radiofrequency ablation. You say that you would like reconsideration because you are in pain. The Plan denied your request. The Plan says this service is considered experimental for the treatment of knee pain.
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 radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure that is the subject of ongoing clinical trials. 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the knee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ongoing inpatient psychiatric care beyond February 28, 2021.
You asked the Plan to pre-approve inpatient psychiatric care. You say that additional inpatient days are required. The Plan denied your request. The Plan says the enrollee can be managed at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care. Our reviewer says that inpatient psychiatric care is not medically necessary at this time. Our physician reviewer found it did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. The health plan's denial of continued inpatient psychiatric services is appropriate. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. This patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve ongoing inpatient psychiatric care beyond February 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy.
You asked the Plan to pre-approve radiation therapy. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 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 radiation therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the intent is clearly palliative (post-op dose radiation to the spine) with low dose of 2 Gy x 10, in an enrollee with widespread disease from multiple myeloma and there is no plausible rationale for what benefit image-guided radiation therapy (IGRT) would afford. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve radiation therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 does not require the intensity of services provided at an
IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and
regular physician evaluation. 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.