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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF care. The Plan denied your request. The Plan says the enrollee is medically and neurologically stable and does not require intensive therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient presented to ED 12/14/2019 with left sided weakness with lethargy. CT head in ED showed hypo density concerning for acute/subacute infarct in right frontal and parietal lobes in addition to old bilateral infarcts. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient required the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAlpha-stim system (Cranial Electrical Stimulation) (E1399) to be provided by "the doctor".You asked the Plan to pre-approvethe Alpha-stim system. You say that you are appealing because you have tried every antidepressants along with many sessions with a counselor or psychiatrist.The Plan denied your request. The Plan says the request for a stimulation device to be used at home exceeds your needs and therefore not a covered benefit.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 Alpha-stim system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Alpha-stim system (Cranial Electrical Stimulation) is covered for the treatment for beneficiaries however it is considered an adjunct to medication and counseling. Based on the information provided this enrollee does not show in the records failure of traditional psychotherapy. Therefore, the Alpha-stim system is not considered medically necessary as the criteria is not 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 Alpha-stim system have not been met.Therefore, we decided that the Plan does not have to pre-approveAlpha-stim system (Cranial Electrical Stimulation) (E1399) to be provided by "the doctor".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance for use with the compression device (E0667). You asked the Plan to pre-approve a pneumatic compression device and segmental pneumatic appliance. You say that the enrollee has tried a basic device.The Plan denied your request. The Plan says the record does not contain documentation of a four week trial.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Though it is noted that the enrollee has had a trial of E0651, the length of the trial is not documented.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmental pneumatic appliance for use with the compression device (E0667)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that the requested orthotics are medically necessary for you. You say that you have had two surgeries on your knee and cannot walk straight.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-approvefoot orthotics.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for additional routine transportation trips to be provided.You asked the Plan to pay for the additional trips. You say that you have appointments and does not have anyone to to rely on to get to your appointments. You say you had a total knee replacement and has had 3 seizures so you are not allowed to drive.The Plan denied your request. The Plan says the benefits have been 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 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of the additional trips.Therefore, we decided that the Plan does not have to pay for additional routine transportation trips to be provided .
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 pontics and one additional retainer crown.You asked the Plan to pre-approve the pontics and additional retainer crown. You say that you are allowed 2 crowns per calendar year.The Plan denied your request. The Plan says the maximum benefit for crowns was reached. The Plan also says that pontics are not covered by Medicare or by the plan's enhanced 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 pontics are not among those covered under this benefit. Also, crowns are limited to 2 crowns per calendar year. The record shows that you received a crown on May 23, 2019 and your crown benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approve 2 pontics and one additional retainer crown.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network provider.You asked the Plan to pre-approvethese services. You say that the enrollee believes there are no network providers that can treat him.The Plan denied your request. The Plan says the services areavailable from network providers.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 pre-approved care.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-approvethe medical services to be provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental implants.You asked the Plan to pre-approvedental implants. You say that you need these because your dentures will not stay in.The Plan denied your request. The Plan says that this is not a covered benefit of your plan.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-approvedental implants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive a copayment for Physicianservices (G8432, G8419, 99213, G8427) provided February 26, 2018 to November 9, 2018. You asked the Plan to waive a copayment forthe physician services. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment 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 $15 copayment for Physician Visits with your Primary Care Physician (PCP). You have been asked to pay a $15 copayment. The physician services at issue fall within the Physician Visits with your Primary Care Physician (PCP) 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 a copayment for Physician services (G8432, G8419, 99213, G8427) provided February 26, 2018 to November 9, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEstradiol.You asked the Plan to pre-approveEstradiol. You say that you have been stable on this medication since 2015.The Plan denied your request. The Plan says that this is not covered under 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 drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveEstradiol.Benefits for Estradiolmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveSeysara 100mg tablets.You asked the Planto pre-approvethe Seysara tablets. You say that this medication is necessary for the enrollee's condition.The Plandenied your request. The Plansaysthis oral drug is not covered by Medicare Part B. Coverage must be requested of a Part D plan.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 Plandoes not haveto pre-approveSeysara 100mg tablets.Benefits forthe Seysara tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network provider.You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are available with in-network providers.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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avonex Pen Kit.You asked the Plan to pre-approve Avonex Pen Kit. The Plan denied your request. The Plan says the enrollee has no Part D pharmacy 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 Avonex Pen Kit.
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 enrollee's condition has declined in the home health setting and a more intensive level of care is needed.The Plandenied your request. The Plan says the enrollee's medical condition is stable and hospital care is not medically needed.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 underwent open reduction and internal fixation of the right hip on 12/16/2019. 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: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean albuterol inhaler 90mcg.You asked the Planto pre-approvethe inhaler. You say that you need this inhaler due to your pneumonia.The Plandenied your request. The Plansaysthis self-administered medication is not covered by Medicare Part B. Part D coverage must be requested.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 Plandoes not haveto pre-approvean albuterol inhaler 90mcg.Benefits for the inhalermay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 medical records provided support the need for IRF care.The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria for an IRF admission.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 physician reviewer found that the documentation does not reveal that the enrollee required the intensity of an IRF stay with close physician or nursing supervision. Our physician reviewer found that the enrollee may benefit from and participate in additional therapy of physical and occupational therapy, but that the enrollee's functional level does not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for an ischemic stroke in the setting of medication non-compliance. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC 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-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) for the enrollee.You asked the Plan to pre-approve a total electric hospital bed. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the plan.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says SNF care would be approved, if requested.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 is currently undergoing treatment at an ACH for a hip joint infection. The enrollee is receiving wound care and a prolonged course of antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time 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 haveto pre-approve admission to a long term acute care hospital (LTACH).