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

We decided that the Plan does not have to pre-approve Gemtasa.
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 self-administered drugs are not covered.
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 Gemtasa.
Benefits for these services 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 the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is 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 the Intracept procedure. Our reviewer says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of intervertebral disc degeneration. The Intracept procedure is experimental for back pain. More research is needed to show safety and efficacy of the procedure. 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex device (22869, 22870).
You asked the Plan to pre-approve 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 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 is experimental. More research is needed to show that 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex device (22869, 22870).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy and low level/cold laser light therapy to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve the physical therapy and low level/cold laser light therapy. The Plan denied your request. The Plan says the physical therapy services can be provided in-network. The low-level laser therapy is not considered reasonable and medically necessary by Medicare.
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.
Medicare rules say that low level/cold laser light therapy is considered not reasonable and necessary under SSA 1862(a)(1)(A) and is not payable by Medicare. This procedure is considered non-covered billed under any HCPCS/CPT codes, including S8948 and 97039. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the physical therapy at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Also, Medicare considers low level/cold laser therapy not reasonable and necessary and non-covered. Therefore, we decided that the Plan does not have to pre-approve physical therapy and low level/cold laser light therapy to be provided by the requested out-of-network provider.
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 want to avoid going to a skilled nursing facility
because of the care you received there. The Plan denied your request. The Plan says the you do not have
complex rehab needs that can only be met at an IRF.
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 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. The patient does require physical and occupational therapy but there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for kidney failure and dialysis. Medical conditions are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. 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: 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. You say that you have been a paraplegic for 33 years and you had to be bed ridden to heal a sacral wound. You say that you are asking for coverage in a SNF for rehabilitation due to your weakened condition from being in bed to heal this wound. The Plan denied your request. The Plan says based on review of your clinical history and notes from your primary care provider, you do not meet criteria for skilled rehabilitation. Your care is more appropriate for custodial or long-term 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 medically necessary. Our physician reviewer found that based on the medical records, you have remained medically stable. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function and transfers, as a practical matter, the intermittent skilled services can be provided at a lower level of care other than a skilled nursing facility. You do not have any parental medication; daily complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy services.
You asked the Plan to pre-approve massage therapy services. You say that this service has improved your back
pain. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore,
we decided that the Plan does not have to pre-approve massage therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator and extra battery.
You asked the Plan to pre-approve a this equipment. You say that this equipment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The rules say that duplicate equipment is not covered. The medical records show that you have stationery oxygen and portable tanks for use in the home. Your medical condition does not require additional equipment inside the home. Portable oxygen equipment is not covered for use outside of the home. Therefore, we decided that the Plan does not have to pre-approve this equipment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE).
You asked the Plan to pre-approve the TTE. You say that the records provided support the need for the
requested imaging services. The Plan denied your request. The Plan says the records show that the same study
or a test like it has been done for you. The Plan says that they also show the results of this test. The Plan says
that the prior study showed the doctor what they needed in order to treat the enrollee.
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 TTE. Our reviewer says that a TTE
is not considered medically reasonable and necessary in this case. Our physician reviewer found the review
indicates that the same study had been approved and completed on June 15, 2021. Repeat imaging less than one
month later is not supported by medical necessity criteria.
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 TTE have not been met. Therefore, we decided that the Plan does not have
to pre-approve transthoracic echocardiography (TTE).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cosmetic surgery services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the surgery services. The Plan denied your request. The Plan says the services are available in-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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve cosmetic surgery services to be provided by an out-of-network provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for chronically ill patients (S9986).
You asked the Plan to pre-approve special supplemental benefits. You say that you suffer from thyroid, high blood pressure and numbness in your fingers. The Plan denied your request. The Plan says the enrollee does not meet the criteria to receive special supplemental benefits for the chronically ill.
The Plan must follow Medicare rules. However, the Plan offers a special supplemental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply. The Plan's rules say to be eligible for the additional benefits, you must have one or one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. The enrollee does not have an eligible chronic condition listed on pages 102-103 of the Evidence of Coverage. Based on this information, we decided that Medicare rules for coverage of special supplemental benefits have not been met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for chronically ill patients (S9986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic devices (L8702).
You asked the Plan to pre-approve the orthotic. You say that the Plan has previously authorized this device in the last 12-month deeming the MyoPro 2 medically necessary. The Plan denied your request. The Plan says this item is considered investigational in nature with no long-term outcome data or continuation rate data at this time.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic devices (L8702).
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

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 there are no complex nursing or rehabilitation needs. You do require physical and occupations therapy, but there is no documented need for an intensive rehabilitation program.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional physical therapy visits.
You asked the Plan to pre-approve 2 additional physical therapy visits. You say that the additional 2 physical therapy visits are medically necessary. The Plan denied your request. The Plan says the additional 2 physical therapy visits are 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 2 additional physical therapy 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 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 is at a high functional level and should be able to transition to an independent home exercise program with the authorized therapy. The requested services are not part of a maintenance program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 2 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional physical therapy visits.
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 care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.

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 based on the documentation provided, it is my opinion that the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is functioning at her baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 SNF care 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: Other
Decision: Favorable

We decided that the Plan has to pre-approve a continuation of care with an OON provider.
You asked the Plan to pre-approve the continuation of OON care. You say that you have been seeing the
requested provider for several years. The Plan denied your request. The Plan says that the one visit that was
approved for the requested OON provider will be sufficient in facilitating a smooth transition of care. The Plan
says that medically necessary services are available within the enrollee's network.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you
must use contract providers for care.
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 continuation of OON care. Our
reviewer says that the criteria for coverage of continued OON have been met. Our physician reviewer found the
enrollee suffers from an uncommon complication after facial paralysis, which is dystonia and spasms of the
face. Because it's an uncommon complication, not all otolaryngologists are able to treat this condition. It
requires specialized treatment from a facial plastic surgeon who is board certified to treat this particular
condition. If it is performed incorrectly, it can lead to worsening facial paralysis for the enrollee. The plan has
not shown that they have in-network specialists for this condition. The plan listed general otolaryngologists.
They did not provide a list of facial plastic surgeons. With the information provided, the plan has not
substantiated their denial reason or proven that the enrollee can be safely transitioned to an in-network
specialist.
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 continuation of OON care have been met. Therefore, we decided that the
Plan has to pre-approve a continuation of care with an OON provider.