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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings.

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 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 surgical treatment of a hip fracture after a fall. Medical problems 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, 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. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular (knee) nerves.
You asked the Plan to pre-approve the RFA procedure. You say that the enrollee would benefit from this treatment. The Plan denied your request. The Plan says this 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 the RFA procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is still considered an experimental/investigational procedure whose role in the treatment of knee osteoarthritis is still being defined. It is the subject of ongoing clinical trials. Therefore, the request is considered not medically reasonable or necessary at this time. 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 RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular (knee) nerves.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Mitomycin for the enrollee.
You asked the Plan to pre-approve a tier exception. You say that the patient cannot afford the copay. The Plan denied your request. The Plan says that Medicare rules say tier exceptions are not available for drugs/devices covered by Part B.
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Mitomycin for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power expandable controller (E2377), harness (E2313), and electrical connection (E2311) for a power mobility device.

You asked the Plan to pre-approve power mobility device accessories. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for these accessories is correct, because the approved wheelchair accessories already come with switches which the enrollee is able to use.

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 power mobility device accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not show that the enrollee requires other types of proportional input devices or non-proportional devices. The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. The enrollee's strength and function in the upper extremities with the ability to feed herself independently indicates that the enrollee can control any power options through their own individual switches.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power mobility device accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power expandable controller (E2377), harness (E2313), and electrical connection (E2311) for a power mobility device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 has lumbar spinal stenosis. The requested Superion spacer remains experimental in nature, as more research is needed to show its safety and efficacy. Open laminectomy surgery remains the gold standard procedure for spinal stenosis. The Superion spacer 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no skilled need.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found in this case, the documentation doesn't support that the enrollee requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The enrollee does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. She requires custodial care without any skilled needs therefore a home health aide 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device at L3-L4 for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 Vertiflex device remains experimental. More research is needed to show safety and efficacy. Open laminectomy remains the gold standard for spinal stenosis treatment. 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 Plan does not have to pre-approve the Vertiflex Superion device at L3-L4 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for foot orthotics with an out-of-network provider.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available and there is no gap issue.

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 a referral for foot orthotics with an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 9 skilled nursing visits.

You asked the Plan to pre-approve the skilled nursing visits. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records do not support that this request is medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 skilled nursing visits. 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 documentation does not support that the enrollee requires additional skilled nursing services to provide treatment that is medically necessary. The enrollee does not require skilled nursing services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The documentation supports that the previous 12 skilled nursing home visits were adequate to teach the enrollee and his family regarding disease monitoring and treatment. The additional nursing visits 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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the 9 skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for physical therapy.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no gap in coverage and there are participating providers in the area where services can be obtained.
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 a referral out-of-network for physical therapy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for an extended SNF stay. The Plan denied your request. The Plan says the enrollee does not have daily skilled nursing or skilled therapy needs.
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 necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy and occupational in the SNF. By the dates in question, the enrollee was at maximal assist level with functional mobility or required a mechanical lift for transfers. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion exercise device (CPM) (E0935).

You asked the Plan to pre-approve the CPM device. You say that you cannot straighten your knee and you believe the device should be covered. The Plan denied your request. The Plan says the CPM device must be used within two days of surgery and cannot be approved longer than 21 days.

The Plan must follow Medicare rules. The rules say that CPM devices are covered only if use of the device began within two days of receiving total knee replacement surgery.

Records show that total knee replacement surgery. Use of a CPM device has not yet begun. This means that use of a CPM device was not started until more than two days had elapsed following total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion exercise device (CPM) (E0935).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutment (D6057) for teeth # 12 and 13, and abutment supported crowns (D6059) for teeth # 12 and 13.
You asked the Plan to pre-approve the dental services. You say that the services were previously covered by the enrollee's plan. You say that the coverage for the services were suddenly discontinued as of 2020. You say that by not replacing the implants entirely will cause further problems with the enrollee's chewing function, tempomandibular joint pathology, as well as facial asymmetry. The Plan denied your request. The Plan says the requested services 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. The record shows that the Plan sent out a 2020 Annual Notice of Changes on August 2, 2019. The requested services have not been covered since the 2020 benefit year. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutment (D6057) for teeth # 12 and 13, and abutment supported crowns (D6059) for teeth # 12 and 13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture.
You asked the Plan to pre-approve the maxillary partial denture. You say that you would like the denture to be approved. The Plan denied your request. The Plan says this service is limited to once every 5 years.
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, dentures are limited to one per arch every 5 years. The record shows that you received a maxillary partial denture on June 26, 2019 and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions, removals of mandible extosis, and jaw reconstruction.

You asked the Plan to pay for the extractions, removals of mandible extosis, and jaw reconstruction. You say that you do not feel that these services were provided for cosmetic reasons. The Plan denied your request. The Plan says these services are not covered under your medical benefits. The Plan also says that these services are primarily dental in nature.

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. These services were done in order to allow for replacement of teeth, is considered dental in nature, and is not listed as a Medicare-covered service in the EOC. The record also shows that you used up the $200 allowance for non-Medicare covered dental services prior to this date of service, hence no payment is allowed for these services. Therefore, we decided that the Plan does not have to pay for the extractions, removals of mandible extosis, and jaw reconstruction.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care.

You asked the Plan to pre-approve inpatient psychiatric care. You say that the requested services are medically necessary. The Plan denied your request. The Plan says coverage criteria for inpatient psychiatric care are not met.

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 it does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care. Our physician reviewer found that you do not appear to require inpatient mental health treatment as you are not a danger to self or others and are cooperative with care without any aggressive behaviors.

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 inpatient psychiatric care.