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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's condition is not medically complex, and does not require an interdisciplinary approach/multiple specialists to oversee rehab care.
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. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xidra 5% eye drops.

You asked the Plan to pre-approve the Xidra. You say that the enrollee has been compliant with her eye drops, but continues to have corneal staining and remains symptomatic while on Restasis. The Plan denied your request. The Plan says the enrollee is on an MA only plan and does not have a prescription drug coverage plan. The plan says that the request for Sidra should be processed under a Medicare 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 Plan does not have to pre-approve Xidra 5% eye drops.

Benefits for the Xidra 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty services (CPT D7310), maxillary interim complete dentures (D5810) and bone replacement graft services for ridge preservation (D7953).
You asked the Plan to pre-approve the alveoloplasty services, the maxillary interim complete dentures, and the bone replacement graft services. You say that The Plan denied your request. The Plan says the services which remain in dispute are not covered benefits under Medicare or the 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 services which remain in dispute are not among those covered under this benefit. The services which remain in dispute are to be performed, following the covered extractions, in order to prepare for dental implants. These types of services are not listed as covered benefits and are specifically excluded in the contract language. Therefore, we decided that the Plan does not have to pre-approve alveoloplasty services (CPT D7310), maxillary interim complete dentures (D5810) and bone replacement graft services for ridge preservation (D7953).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the remaining 12 denied physical therapy (PT) visits.

You asked the Plan to pre-approve the remaining 12 denied physical therapy (PT) visits. You say that the remaining 12 PT visits are medically necessary. The Plan denied your request. The Plan says the remaining 12 PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the remaining 12 denied physical therapy (PT) visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee underwent right total knee replacement on 11/18/2019. He has received a total of 12 outpatient physical therapy treatment sessions. 12 additional sessions are being requested. Based on the therapy records provided the enrollee has essentially reached his goals with outpatient physical therapy through the initial 12 sessions, further rehabilitation through a home exercise program appears to be indicated 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 remaining 12 denied physical therapy (PT) visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the remaining 12 denied physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cyclobenzaprine 5mg tablets.
You asked the Plan to pre-approve cyclobenzaprine tablets. You say that this medication is necessary. The Plan denied your request. The Plan says this oral drug cannot be covered by Medicare 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 cyclobenzaprine 5mg tablets.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on June 18, 2019.You asked the Plan to pay forthe eye exam. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay foran eye exam providedon June 18, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on October 9, 2019.
You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the anesthesia services provided on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 3, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available and requires authorization for certain 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 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 3, 2019.
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 you feel that this should be covered because multiple providers have said this is the best option for you. The Plan denied your request. The Plan says your medical condition is not such that you require the intensity of service of the IRF. You do not require three hours a day of daily 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 enrollee was admitted to the hospital on 1/21 after a bicycle accident resulting in pelvic fractures for which he went open surgical fixation. He is currently non-weight bearing in the left lower extremity. He requires moderate assist with sit to stand, minimal assist with transfers and can ambulate only up to three steps with a wheeled walker. Based on available records, the patient does not meet criteria for coverage of IRF. The patient is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While he may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvecomputed tomography (CT) of the chest and abdomen.You asked the Plan to pre-approvethe CT of the chest and abdomen. You say that the records provided support the need for the requested CT scan services.The Plan denied your request. The Plan says that the records do not show the results of a recent chest x-ray, testing of the electrical actions of the enrollee's hear, or testing to show how well the enrollee's lungs are working to carry oxygen to the body. The plan says that detailed picture studies are not supported without these results.The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT of the chest and abdomen. Our reviewer says that CT of chest and abdomen is medically reasonable and necessary. Our physician reviewer foundthe enrollee has a past medical history of oral cancer and chronic obstructive pulmonary disease (COPD) who presented on January 16, 2020 with a recent severe worsening of dyspepsia despite omeprazole 20 mg daily. On examination, he had epigastric tenderness without note of any guarding or rebound. He had end expiratory wheezes on lung exam. Oxygen saturation was 99 % on room air. The treatment plan was to refer to gastroenterology and check CT of chest and abdomen to evaluate for masses, given his historyof oral cancer. In this case, the concern for potential metastatic disease as a cause for recent significant worsening of dyspepsia is reasonable given the history of oral cancer.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 CT of the chest and abdomen have not been met.Therefore, we decided that the Plan has to pre-approvecomputed tomography (CT) of the chest and abdomen.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.
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 you wish to have intensive therapy so you can return to function as soon as possible. The Plan denied your request. The Plan says there is no need for acute medical care or an intensive rehab program.
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 is a female who was struck by a vehicle and suffered a right sacral fracture, right pubic symphysis fracture, and a right acetabular fracture. The member requires pain control with Oxycodone and is on Lovenox for blood clot prevention. Co-morbid conditions include obesity and prior total hip replacement. Now, pain appears well managed and the member is hemodynamically stable. Records do not indicate that there are significant, or complex medical/nursing issues that would require frequent physician oversight in an inpatient hospital setting. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. In this case, the member is mostly MIN assist for functional transfers and ADL's and a less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period. 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 Plan does not have to pre-approve Diclofenac sodium 1% gel for the enrollee.
You asked the Plan to pre-approve the gel. You say that this is medically necessary. The Plan denied your request. The Plan says this should be processed under the enrollee's Medicare Part D plan, and not under the Part B 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 Plan does not have to pre-approve Diclofenac sodium 1% gel for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.
You asked the Plan to pre-approve these services. You say that you are concerned for the enrollee's safety. 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 enrollee was admitted to the hospital with sepsis. He was treated for the sepsis and acute on chronic kidney failure. He received physical, speech, and occupational therapy in the hospital and needs assistance with functional mobility, including walking to 250 feet with a rolling walker. He needs varied assistance with activities of daily living. He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea replacementscooter.You asked the Plan to pre-approvea replacement scooter.You say that your scooter broke down again and you can't go anywhere without it.The Plan denied your request. The Plan says your current scooter is not irreparable.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The rules also state that for equipment to be covered, it must be appropriate and needed for use inside the home.The file shows that you have a scooter received on November 8, 2017. This scooter received on November 8, 2017 serves the same purpose as a new scooter. The record shows your scooter is still under reasonable useful lifetime and is reparable. Therefore, we decided that the Plan does not have to pre-approvea replacement scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on April 2, 2019 by the out of network provider.
You asked the Plan to pay for an office visit. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service April 2, 2019. Patient services were rendered based upon a medical condition. You are requesting to have documents reviewed and process the claim as services were urgently needed and medically necessary. The Plan denied your request. The Plan says the rendering provider is a non-participating provider. The plan did not authorize any services for E-medical Practice or the physician. There are multiple in-network providers within 30 miles of the members residence that could have rendered the services. The services are not considered urgent/emergent in nature.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on April 2, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe posterior resin based composite (D2391) provided on August 22, 2019.You asked the Plan to reimburse you forthe posterior resin based composite. You say that you were informed when you signed up for your Plan that you had $2,000 benefit coverage annual. You also say that you do not understand why this bill was not covered. The Plan denied your request. The Plan says the frequency limit for fillings has been exceeded.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 and fillings are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for 2 fillings that you received on August 22, 2019.Therefore, we decided that the Plan does not have to reimburse you forthe posterior resin based composite (D2391) provided on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).
You asked the Plan to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you are covered for Partial dentures every 5 years. The Plan says that you were provided this service on May 29, 2019. The Plan says that they contacted your dental provider who advised that you may contact their office to schedule an appointment for adjustment of your current dentures.
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 Partial dentures (D5213 and D5214) are only covered under this benefit every 5 years. The file shows that you last received Partial dentures on May 29, 2019. The Plan confirmed with your dental provider that you can schedule an appointment for adjustment of your current dentures until they fit properly. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).