Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard.
You asked the Plan to pre-approve an occlusal guard. You say that you need this device sue to your sleep
apnea. The Plan denied your request. The Plan says the requested device is not a covered benefit.
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
occlusal guard.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ongoing care to be provided by an out of network (OON) provider.You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve ongoing care to be provided by an out of network (OON) provider.
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 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. 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on June 1, 2020 with altered mental status due to acute encephalopathy of unclear etiology, acute kidney injury with hyperkalemia, and severe sepsis. He is receiving acute care at the current hospital. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently
acquired computed tomography (78815).
You asked the Plan to pre-approve a PET scan. You say that the enrollee is at high risk for recurrence. The Plan
denied your request. The Plan says there is no evidence that there is a concern of the enrollee's cancer
recurring.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are
medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that the
criteria for coverage have not been met. Our physician reviewer found in the absence of signs or symptoms,
routine imaging is not indicated.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography
(78815).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lyrica for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered by Part B.
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 Lyrica for the enrollee.
Benefits for this drug 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve the additional routine transportation. You say that you would like reconsideration because the member has been referred to specialists for further evaluation and requires assistance with transportation. The Plan denied your request. The Plan says the member has used 36 routine transportation trips so the benefit is exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the member has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 6, 2018 to May 9, 2018.You asked the Plan to pay for acute inpatient hospital care. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this hospital stay does not meet the Medicare criteria for inpatient care and meets the criteria for observation care instead.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 documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was noted to remain stable throughout the hospital course. Care provided to the enrollee was observation level. There were no advanced interventions or complex medical conditions. The enrollee had stable vital signs and stable clinical findings throughout the hospital course. Inpatient services were therefore not supported by the documentation. 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 not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 6, 2018 to May 9, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a nuclear stress test. You say that the facility the procedure is being done at is out-of-network however the doctor is in-network. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and this test can be provided at an in-network facility.
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 the medical services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON SNF care. You say that this is medically necessary. The Plan denied your request. The Plan says you can receive care 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 provider at issue in this case is not a network provider with the Plan. 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 OON SNF care. Our reviewer says that the criteria for coverage of an OON facility has not been met. Our physician reviewer found it is not medically necessary for you to receive care at the requested out-of-network facility rather than an in-network facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OON SNF care have not been met. 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 OON SNF care. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humalog.You asked the Plan to pre-approve the Humalog. You say that the enrollee has a poor understanding of insulin and renal insufficiency. You say that the enrollee has been on Humalog for years and that you don't want to change for her safety.The Plan denied your request. The Plan says the enrollee does not have a Medicare Part D benefit or separate pharmacy benefit managed under the enrollee's contract.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 Humalog.Benefits for the Humalog 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care.
You asked the Plan to pre-approve home health care. You say that you need home health care instead of a skilled nursing facility due to COVID-19. The Plan denied your request. The Plan says this would be non-covered custodial care.
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be 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 home health care. Our reviewer says that the criteria for home health services has not been met. Our physician reviewer found the records show that you are not home-confined. While you could benefit from outpatient services, home health care is not appropriate and 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 home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you need assistance regaining strength. The Plan denied your request. The Plan says the admission 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the hospital on June 3, 2020 for a flare up of chronic back pain. You received oral medications and had stable vital signs. You were effectively treated for pain. You received physical therapy in the hospital and need assistance with bed mobility and transfers. You use a wheelchair and are able to self-propel 360 feet. You have skilled nursing and skilled therapy needs but do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 records provided support the need for care in an IRF. The Plan denied your request. The Plan says the records do not indicate that the enrollee meets the criteria for coverage of IRF care. The Plan says that the hospital records show that the enrollee's medical conditions have improved and that care can safely be received in a less intensive 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 require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 clinical information supports the admission to an IRF. The Plan denied your request. The Plan says the records received do not show that the enrollee needs to be seen by a rehabilitation doctor three times per week. The Plan says that the enrollee does not need an intensive team for care. 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 require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean oximeter (E0445).You asked the Plan to pre-approvean oximeter. You say that this is necessary for the enrollee's condition.The Plan denied your request. The Plan says this is not covered.The Plan must follow Medicare rules.Medicare rules say that oximeters  will be denied as non-covered because they are monitoring devices that provide information to physicians to assist in managing the beneficiary's treatment.We looked at the file and Medicare rules. The requested item isa non-covered oximeter. Based on this information, we decided that Medicare rules for coverage of an oximeter have not been met.Therefore, we decided that the Plan does not have to pre-approvean oximeter (E0445).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard wheelchair. You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says there was no documentation that the mobility limitation cannot be sufficiently resolved by the use of a cane or walker. 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 wheelchair. Our reviewer says that the requested wheelchair is not considered medically reasonable and necessary in this case. Our physician reviewer found you have a mobility limitation but the documentation does not reveal that it significantly impairs your ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. It is not clear that a manual wheelchair will significantly improve your ability to participate in MRADLs. Although you have shoulder arthritis it is not clear that your mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted walker. There is no evidence of a detailed shoulder exam or upper extremity exam indicating deficits of range of motion or strength. You have a caregiver who is willing to assist with the wheelchair. The criteria for a standard wheelchair per Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788) have not been met. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve skilled nursing services. You say that you would like approval for these skilled nursing services. The Plan denied your request. The Plan says there are in-network providers available for these 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 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 skilled nursing services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darzalex.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is recently diagnosed with multiple myeloma. An undated letter states that Cytoxan is not being used at this time due to her comorbidities. The visit note of May 19, 2020 states that Revlimid is not being prescribed due to recent gastrointestinal bleed and inability to use anticoagulation. The requested combination with Darzalex is not FDA-approved and not supported in Medicare-approved compendia. The requested use of Darzalex, with or without Revlimid or Cytoxan, is not safe and effective or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve Darzalex.