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

We decided that the Plan does not have to pre-approve a lumbar laminectomy/discectomy for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says more information about the diagnosis and planned surgery is needed.

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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a recent trial and failure of physical therapy. There is no imaging study showing severe nerve compression.

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar laminectomy/discectomy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

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 you do not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met.

We looked at the file and Medicare rules. The file shows that you are not insulin-treated. 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 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alert or alarm device (A9280).

You asked the Plan to pre-approve this item. You say that an alert device is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.

The Plan must follow Medicare rules. Medicare rules say that alert systems are not covered because they are emergency communication systems that do not serve a diagnostic or therapeutic purpose.

While an alert system may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve an alert or alarm device (A9280).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical removal of an erupted tooth.

You asked the Plan to pre-approve surgical removal of an erupted tooth. You say that the service is necessary. The Plan denied your request. The Plan says the requested service 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 surgical removal of an erupted tooth.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine (72148), an MRI of any joint of the upper extremity (73221), and an MRI of the spinal canal (72141).

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 these services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found that you were diagnosed with lumbar radiculopathy. You have reported headaches, cervical pain, thoracic pain, and lumbar pain. The record indicates that you have hypertonicity of the spine and reduced range of motion. Adjustments of the spine were performed as treatment. You did not present with report of any red flag symptoms or physical findings to justify the MRI services requested. Additionally, there was no documentation of failure of conservative treatments such as physical therapy. Therefore, your request for these services will be considered as not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine (72148), an MRI of any joint of the upper extremity (73221), and an MRI of the spinal canal (72141).
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 member's nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. The member continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation does not support that the member would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the member would tolerate skilled rehabilitation in an IRF, participating in rehab services fifteen (15) hours a week. The member is ambulating up to twelve (12) feet with minimal assistance but poor endurance. The member can receive services 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair and mechanism.

You asked the Plan to pre-approve a seat lift chair and mechanism. You say that the Plan denied your request. The Plan says this item is not a covered benefit because it is considered a convenience item.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed are met.

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 seat lift chair and mechanism. Our reviewer says that based on the medical records provided there is no documentation that the member meets all the criteria for the seat lift mechanism. Our physician reviewer found the records do not document that the member is completely unable to stand up from a regular armchair or any chair in the home.

Additionally, the rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism. Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that Medicare covers.

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 seat lift chair and mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair and mechanism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.

You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically necessary. The Plan denied your request. The Plan says the documentation shows the power wheelchair is intended for community use.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home.

Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic test strips to be provided by a non-preferred brand (OneTouch Ultra Blue Test Strip).

You asked the Plan to pre-approve diabetic test strips to be provided by a non-preferred brand. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be provided by a preferred brand.

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 diabetic supplies from non-preferred brand only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested brand is not a preferred brand of the Plan. The Plan has preferred brands available that can provide the items at issue in this appeal. The documentation does not support why the non-preferred brand is medically necessary for the enrollee. 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 diabetic test strips to be provided by a non-preferred brand (OneTouch Ultra Blue Test Strip).
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 in the Medicare rules section.

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
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the medical records
provided the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require
physical therapy and occupational therapy services but based on the medical records provided the enrollee does
not require an intensive inpatient rehabilitation therapy program. There is no documentation that the enrollee
requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ure-Na (99999).

You asked the Plan to pre-approve Ure-Na. You say that Ure-Na is medically necessary. The Plan denied your request. The Plan says this product is not eligible for coverage under the Part B medical benefit.

The Plan must follow Medicare rules. Medicare rules say that enteral products given orally are not covered by Medicare.

We looked at the file and Medicare rules. Ure-Na is given orally. Oral enteral nutrition products are not covered. Based on this information, we decided that Medicare rules for coverage of Ure-Na have not been met. Therefore, we decided that the Plan does not have to pre-approve Ure-Na (99999).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel.

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 services are not covered.

The Plan must follow Medicare rules. Medicare rules say that procedure code 81455 is non-covered.

We looked at the file and Medicare rules. The testing at issue is a targeted genomic sequence analysis panel described by code 81455. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of SNF services beyond April 28, 2021.

You asked the Plan to pre-approve a continuation of SNF services beyond April 28, 2021. You say that the enrollee needs SNF services.The Plan denied your request. The Plan says continuation of SNF services beyond April 28, 2021 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 in the Medicare rules section 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 a continuation of SNF services beyond April 28, 2021. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The patient has no complex wound care or other SN need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursingor therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.

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 continuation of SNF services beyond April 28, 2021 have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuation of SNF services beyond April 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870).

You asked the Plan to pre-approve the spacer placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.

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 spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Interspinous spacers remain experimental. More research is needed to show safety and efficacy.

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 spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and abutment supported porcelain/ceramic crown (D6058).

You asked the Plan to pre-approve the prefabricated abutment and abutment supported crown. The Plan denied your request. The Plan says these services are not covered under your benefit package.

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 a prefabricated abutment (D6056) and abutment supported porcelain/ceramic crown (D6058).
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation does not support that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab services fifteen (15) hours a week, under the supervision of a physician with at least three (3) visits weekly to regain or maintain your functional status. You are ambulating up to 75 feet with minimal assistance. You are near your prior level of function and could receive services 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 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 in the Medicare rules section.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no records provided which document that the enrollee requires treatment by multiple therapies, including either physical therapy or occupational therapy in an intensive rehabilitation therapy program. There is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation 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 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-approve a manual wheelchair.

You asked the Plan to pre-approve these services. You say that you need the manual wheelchair to go to doctor appointments. The Plan denied your request. The Plan says the services are not covered for use outside of the home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.