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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
care in an LTACH. The Plan denied your request. The Plan says LTACH services are not medically necessary. 
The Plan says that the enrollee's care could be treated at a lower level of care, such as a subacute rehabilitation 
facility. 
 
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 enrollee's ongoing care needs include oral antibiotics, surveillance laboratory 
studies, wound care, and therapy services. The documentation does not support that the enrollee in this case 
requires services at the LTACH that are not available where she is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the chargesforthe podiatry services provided on July 30, 2020.You asked the Plan to waive the charges forthe podiatry services. You say that you do not believe that you were seen by this provider.The Plan denied your request. The Plan says review of the medical records shows that you were seen and had podiatry care provided on this date of service. You are correctly assessed the $50 copayment for this service. The provider may not bill you more than this amount.The rules say a plan must disclose toits enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for Medicare-covered podiatry services. You have been askedto pay a $50 copayment for the podiatry services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the charges forthe podiatry services provided on July 30, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea universal headrest adapter (K0108) for the enrollee.You asked the Planto pre-approvethe adapter. You say that this is medically necessary.The Plandenied your request. The Plansaysthe incorrect code was used.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The requested item does not appear to be primarily medical in nature. Additionally, it appears to be billed using the wrong code.Therefore, we decided that the Plandoes not haveto pre-approvea universal headrest adapter (K0108) for the enrollee.
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 this enrollee requires a long term stay 
with acute care and that an LTACH specializes in this type of patient. The Plan denied your request. The Plan 
says the enrollee can receive necessary care in the current facility. 
 
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 There is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. The requested 
LTACH services are not medically necessary, reasonable, and appropriate. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran x-ray provided on October 23, 2020 by an out of network (OON) provider.You asked the Plan to pay foran x-ray. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-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 pay 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exceptionthat would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran x-ray provided on October 23, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve the dental service. You say that you need the biopsy to determine if you 
have cancer. You say that this is a life or death situation. You say that you have a quarter sized hole in your 
mouth which is very irritated, swollen and painful. You say that you cannot eat due to the pain. You also say 
that you had a biopsy done about a year and a half ago. The Plan denied your request. The Plan says incisional 
biopsy of oral tissue is not a covered service. 
 
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 an 
incisional biopsy of oral tissue (D7286).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay from August 3 to August 7, 2020.You asked the Plan to waive the copayment forthe inpatient hospital stay. You say that you tried to get discharged from the hospital on an earlier date.The Plan denied your request. The Plan says the correct copayment amount has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment per day for days 1-6 for inpatient hospital care. You have been asked to pay a $295 copayment per day for the inpatient hospital stay. Your stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe inpatient hospital stay from August 3 to August 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the clinical information provided supports the medical necessity of LTACH care.The Plan denied your request. The Plan says the medical necessity criteria have not been met.The Plan must follow Medicare rules. The rulessay 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 enrollee is currently undergoing treatment at an acute care hospital (ACH) following surgery on a chronic pressure wound.  The enrollee is not intubated/ventilated.  There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such a time that no acute services are required.  The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.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-approvelong term acute care hospital (LTACH) services.
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 
care in a SNF. The Plan denied your request. The Plan says 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 SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee has remained medically 
stable and has not been admitted to the hospital.  The enrollee does not require skilled nursing and/or skilled 
therapy services on a daily basis.  She is medically stable and can receive further services at a lower level of 
care. Her mental status and functional status are at her baseline and she does not require a higher level of care. 
The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube.  
She is medically stable without any acute exacerbations of chronic medical problems.  Her physical function is 
at or near her baseline and she can receive services at a lower level of care.  Care rendered at a skilled inpatient 
level 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 skilled nursing facility (SNF) 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 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 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete upper denture (D5110) and a complete lower denture (D5120).You asked the Plan to pre-approvethe dental items. You say that your dentures do not fit you anymore. You also say that you need new dentures.The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.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 frequency limit dentures once every 5 years has been reached. The record shows that the Plan paid for dentures that you received on February 20, 2017.Therefore, we decided that the Plan does not have to pre-approvea complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital care provided from February 18, 2020, to February 25, 2020.

You asked the Plan to reduce the copayment for the inpatient hospital care. You say that you should have been released earlier from the hospital and therefore, should have a smaller copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per day for days 1-7. 

You have been asked to pay a $250 copayment per day for the inpatient hospital care. ($250 x 7 days = $1,750). The inpatient hospital care falls within the "Inpatient hospital care" benefit category. The record shows you were still considered an inpatient during these dates of service.

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 reduce the copayment for the inpatient hospital care provided from February 18, 2020, to February 25, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.You asked the Plan to pre-approvethe continued SNF care. You say that the enrollee just started physical therapy and cannot do anything on her own. You say that the enrollee can barely walk eightfeet and does not even leave the room for physical therapy due to CoViD-19. You say that the enrollee still requires help from multiple people to get up.The Plan denied your request. The Plan says 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not support that skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have complex wound care or other skilled nursing needs that requires a SNF stay. The enrollee's functional level with limited weight bearing status does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. Skilled services are not needed on a daily basis or as practical matter in a skilled nursing facility 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 continued SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea right-side facet injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysrepeating the requested procedure is not able to be approved.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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found RFA of the lateral branches of the sacral nerves is considered experimental/ investigational because of the wide variation in efficacy in the peer-reviewed literature. Diagnostic blocks have no long-termefficacy. Therefore, the request is deemed not medically reasonable or 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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea right-side facet injection for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer. 
 
You asked the Plan to pre-approve these services. You say that you cannot walk, you have degenerate bone 
disease and rheumatoid arthritis. The Plan denied your request. The Plan says that this service is considered 
experimental and investigational. 
 
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 requested services are not considered medically reasonable and necessary in this case. The spacer remains 
experimental. More research is needed to show safety and efficacy. There is no documented spinal instability. 
Hardware not needed. Our physician reviewer found that your condition does not meet Medicare criteria for 
these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Superion interspinous spacer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumigan eye drops. 
 
You asked the Plan to pre-approve Lumigan. The Plan denied your request. The Plan says Lumigan 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 Lumigan eye drops.  
 
Benefits for Lumigan may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.