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

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says you exhausted your 100-day benefit limit.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from December 30, 2019 through August 24, 2020. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tracheostomy shower protectors (A7523).
You asked the Plan to pre-approve tracheostomy shower protectors. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested items are considered convenience items and are not covered.
The Plan must follow Medicare rules. Medicare rules say that tracheostomy shower protectors are a convenience item and therefore not covered. Therefore, we decided that the Plan does not have to pre-approve tracheostomy shower protectors (A7523).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were at a barber shop when you passed out and the barber called for an ambulance. You say that when the ambulance arrived, you were awake and you felt fine. You stated that you did not need to go to the hospital and so you refused transport. You say that you were later told that if you had been transported, the charges would have been covered by the Plan. You believe that you saved the Plan thousands of dollars by not being transported and you asked the Plan to reconsider their decision. You say that you are on a fixed income and you cannot afford the charges. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 7, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve Gel-One. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Gel-One. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has osteoarthritis in both knees. The documentation does not support that the enrollee has trialed viscosupplemental treatments such as Orthovisc and Monovisc. The documentation does not outline contraindications or reasons these medications were not considered. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next diabetic test strips.
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 supplies are available from the preferred provider.
The Plan must follow Medicare rules. Medicare rules say that Plans can limit enrollees to specific durable medical equipment and supplies providers. We looked at the file and Medicare rules. The requested services are Contour Next testing strips. Contour Next is not the preferred provider for diabetic testing strips with the Plan. These services are available from the preferred providers of ACCU-CHEK and Trividia. Therefore, we decided that the Plan does not have to pre-approve Contour Next diabetic test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the rehab therapy services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the rehab therapy services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to the enrollee that can provide the requested 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 the rehab therapy services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET/CT scan.
You asked the Plan to pre-approve a PET/CT scan. You say that the requested PET/Scan is medically necessary. The Plan denied your request. The Plan says Medicare does not cover PET imaging for initial anti-tumor strategy for prostate cancer patients.
The Plan follows Medicare rules. Medicare rules say that PET imaging for initial anti-cancer strategy is non-covered for enrollees with prostate cancer. Therefore, we decided that the Plan does not have to pre-approve a PET/CT scan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show improvement on Prolia.
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 Prolia. Our reviewer says that the requested Prolia is not medically necessary. Our physician reviewer found there is no documentation of a trial and failure of first-line bisphosphonates. There are no documented contraindications to first-line bisphosphonate therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dialysis services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the dialysis services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says they have in-network dialysis facilities available that can provide the services you are requesting.
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 dialysis services 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 the enrollee needs LTACH care to regain maximum and prior level of functioning. You say that the enrollee will likely require another 3-4 weeks for transitioning from acute illness. The Plan denied your request. The Plan says the requirements for coverage have not been met. The Plan says that the care needed can be provided in the current inpatient hospital.
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 records show that this enrollee requires additional acute care services, however, based on the clinical course and recent improvements, it is not likely to take more than 24 days. The enrollee does not require any services in the proposed LTACH that are not already available in the current setting. The enrollee may be appropriate for discharge to a lower level of care soon. 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: 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 IRF care. The Plan denied your request. The Plan says an IRF stay is not medically necessary. The Plan says that the enrollee does not require physician assessment and oversight of the program at least 3 times per week and specialized equipment or services. The Plan says that the care needed can be provided in an alternate setting, such as a skilled nursing facility.
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 was medically stable with debility and with no evidence of need for supervision by physical medicine and rehabilitation Physician. There is no evidence of a need for acute rehab nursing care. Functionally, given his current level, though he needs physical therapy and occupational therapy, he does not require IRF level of therapies. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. IRF admission is not medically necessary based on lack of medical complexity. The enrollee's rehabilitation needs can be met at a lower intensity alternate setting, such as a skilled nursing facility or in-home with 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vistaseq panel of genetic testing.
You asked the Plan to pre-approve the genetic testing. You say that the requested testing is medically necessary. You say that the enrollee has a personal history of right breast DCIS and left breast cancer. You say that the enrollee is post status mastectomy, reconstruction, and adjuvant chemotherapy. You say that the enrollee also has extensive family history of malignancy, especially early onset colorectal cancer in both her father and her brother. You say that the clinical notes, lab results, and prior imaging serves to further substantiate the need for a hereditary cancer panel. The Plan denied your request. The Plan says the criteria for coverage have not been met because the enrollee does not have a current diagnosis of cancer. The Plan says that the requested test is not FDA 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 genetic testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the provided records did not show any evidence of this enrollee having a current treatable cancer to justify genetic testing. In this scenario, genetic testing would not lead to any improvement in outcome. She would be considered high risk for cancer and can be placed on a screening program regardless of the results of such testing. 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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vistaseq panel of genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D9222, D9223, and D9612).
You asked the Plan to pre-approve dental services (D9222, D9223, and D9612). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the dental services with dental codes D9222, D9223, and D9612 are not covered by Medicare or the Plan's supplemental dental 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 dental services (D9222, D9223, and D9612).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel One. 
 
You asked the Plan to pre-approve Gel One. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel One. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has unilateral osteoarthritis of the left knee. The enrollee has not trialed 
viscosupplemental treatments such as Orthovisc and Monovisc. The documentation does not outline 
contraindications or reasons these medications were not considered. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel One.
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. You say that you are requesting an expedited appeal because the standard procedure could seriously jeopardize the enrollee's life, health, or ability to regain maximum function. The Plan denied your request. The Plan says Medicare coverage criteria have not been met for admission to an acute IRF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee does not require therapy services in an IRF when he is still acutely ill. Our physician reviewer also found that the enrollee's rehabilitation needs can easily be met in a lower intensity alternate level of rehab such as in a skilled nursing facility setting after attaining medical stability. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says the LTACH admission is 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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our reviewer found that 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. Our physician reviewer also found that 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2750) for tooth #8. 
 
You asked the Plan to pre-approve the crown. You say that the enrollee would like a new crown because of the 
cosmetic impairments. The Plan denied your request. The Plan says that the Medicare coverage criteria has not 
been met. 
 
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 crown 
when the services are medically necessary and reasonable. 
 
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 crown. Our reviewer says that the 
service is medically necessary. Our physician reviewer found due to the defective crown in place on tooth #8, a 
replacement crown (D2750) meets the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-
approve a crown (D2750) for tooth #8.  
 
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.