Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that 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 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 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 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-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee meets the criteria for inpatient rehab, as she is able to cooperate with threehours per day of intensive inpatient physical therapy. You say that the denial of IRF care would be a violation of the standard of care for her post-acute rehab plan.The Plan denied your request. The Plan says the records show the enrollee is medically stable and does not need to be seen by a rehab doctor at least threetimes a week. The Plan says that the enrollee can safely receive the services needed in another setting.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 does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea group four power wheelchair and accessories for the enrollee.You asked the Planto pre-approvethe services. You say that the current wheelchair cannot be upgraded to a group 4 chair.The Plandenied your request. The Plansaysthere is no evidence that the current wheelchair cannot be repaired and modifiedto meet current needs.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. Ourphysician reviewer found a group four power wheelchair has added capabilities that are not needed for use in the home. As the group four wheelchair is not medically necessary the accompanying multiple power accessories cannot be deemed 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea group four power wheelchair and accessories for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve botox injections. 
 
You asked the Plan to pre-approve the botox injections. You say that the botox injections are medically 
necessary. The Plan denied your request. The Plan says this use of this medication is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the botox injections. Our reviewer says 
that the requested botox injections are not medically necessary for the enrollee's diagnosis. Our physician 
reviewer found though trials evaluating the effect of intrapyloric botulinum toxin injection on gastroparesis 
have been reported, there is no agreement whether botulinum toxin can effectively relieve the symptoms and 
improve the results of gastric emptying studies in patients with gastroparesis. 
 
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 botox injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve botox injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the detox services provided from January 25, 2020, to January 28, 2020 by an out of network provider.

You asked the Plan to reimburse you for the detox services. You say that you would like the Plan to reimburse you for the services. The Plan denied your request. The Plan says you did not have authorization for the out of network provider 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 reimburse you for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to reimburse you for these services. Therefore, we decided that the Plan does not have to reimburse you for the detox services provided from January 25, 2020, to January 28, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Austedo. 
 
You asked the Plan to pre-approve Austedo. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Austedo.  
 
Benefits for Austedo 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care rendered from July 19, 2020, to July 
29, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says that the services were not medically necessary. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the services were medically necessary. Our physician reviewer found the enrollee presented to the 
hospital with acute on chronic decompensated heart failure. She underwent an echocardiogram that 
demonstrated an ejection fraction of 10 percent. The records support that, at the time of inpatient admission, the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care rendered from July 19, 2020, to July 29, 2020.  
 
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 the continuation of skilled nursing facility (SNF) after 
January 20, 2021. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says the continued SNF care is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed 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 continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found as of January 20, 
2021, the member does not require any skilled nursing or rehab services on a daily basis. The member does not 
require skilled therapy to establish a safe and effective maintenance program.  The member received skilled 
care with minimal improvement when she was at the SNF, and her function has plateaued by January 20, 2021, 
and she does not require any further inpatient skilled rehab services. The member?s function was at or near her 
prior level of function and she could be discharged to a lower level of care for further 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 the continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) after January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to further reimburse you forthe extraction of erupted tooth (D7210) services provided on September 18, 2020.You asked the Plan to further reimburse you forthe extraction of erupted tooth services. You say that you would like this claim reimbursed up to your $500 benefit total.The Plan denied your request. The Plan says the cost share has applied correctly in this case.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. The Plan covers the extraction of erupted tooth services when the services are medically necessary and reasonable. 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 50% of the billed cost for the dental extraction services.You have been asked to pay a total cost share of $285 for the twoextractions of erupted teeth you received ($570 x 50%). The dental extraction services fall within the oral surgery benefitcategory. 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 further reimburse you forthe extraction of erupted tooth (D7210) services provided on September 18, 2020
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve ForeseeHome monitoring program (visual filed assessment), 
represented by CPT code(s) 0379T. 
 
You asked the Plan to pre-approve ForeseeHome monitoring program (visual filed assessment). 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 must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 ForeseeHome monitoring program 
(visual filed assessment). Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of dry Age-
related macular degeneration (AMD) in the right eye and wet AMD in the left eye. The enrollee is followed 
every 12 weeks and has prophylactic Avastin injection in the left eye at these visits. ForeSee device is a home 
monitoring system for AMD. The system is daily test to check for changes in the vision to detect a conversion 
to wet AMD. The device is appropriate for AMD enrollees who are at high risk for choroidal 
neovascularization because of the presence of bilateral large drusen or who have preexisting wet AMD in one 
eye. Based on these criteria, the enrollee, who has a history of wet AMD in one eye, would benefit from this 
home monitoring system. Therefore, the enrollee meets criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ForeseeHome monitoring program (visual filed assessment) have been met. 
Therefore, we decided that the Plan has to pre-approve ForeseeHome monitoring program (visual filed 
assessment), represented by CPT code(s) 0379T.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
require an intensive, complex, multidisciplinary approach to daily therapy. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for recurrent falls. His medical conditions are stable. The 
complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that he will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
While the medical record documents a need for physical and occupational therapy, it does not document a 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. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe nerve block injections to be provided by an out of network provider.You asked the Plan to pre-approvenerve block injections from an out of network provider. You say that you are not happy with the recommended provider's service.The Plan denied your request. The Plan says the requested provider is not contracted to provide the nerve block injections.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 providerwith 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-approvethe nerve block injections to be provided by an out of network provider
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spiriva. 
 
You asked the Plan to pre-approve Spiriva. You say that the enrollee is out of medication. The Plan denied 
your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs. 
 
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 Spiriva.  
 
Benefits for Spiriva 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

Wedecided that the Plan does not have to-pre-approveadditional supplies for the continuous glucose monitor.You asked the Plan to-pre-approveadditional supplies. You say that 2 sensors does not cover an entire month.The Plan denied your request. The Plan says additional supplies are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered under certain medical indications. We looked at the file and Medicare rules. Additional supplies for the continuous glucose monitor are considered not reasonable and necessary.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to-pre-approveadditional supplies for the continuous glucose monitor.
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to not be hemodynamically stable and requires additional acute 
care services to stabilize which can more safely be administered at the current facility. The patient does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the patient requires that are not already available and covered at the current facility. Transfer may 
be considered when the patient is more stable. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Vertiflex device for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is a lack of evidence to support that these devices are as safe and effective as gold standard of decompression.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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy. There is no spinal instability. The hardware not needed.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 device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Vertiflex device for the enrollee