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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. You say that you need SNF services. The Plan denied your request. The Plan says your needs can be met at a lower level of care.
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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient does not require skilled nursing services with the specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge, and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) for the lower right quadrant and upper right quadrant.

You asked the Plan to pre-approve the scalings and planings. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says this service is allowed one time every 36 months per quadrant. The Plan also says that you have received this service on the lower right and upper right quadrants less than 36 months ago.

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, periodontal scaling and root planing is limited to one per quadrant every 36 months. The record shows that you received periodontal scalings and root planings (D4341) of the lower right and upper right quadrants on December 19, 2019 and your periodontal scaling and root planing (D4341) benefits for the lower right and upper right quadrants has been exhausted. Therefore, we decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) for the lower right quadrant and upper right quadrant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0807).
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the most appropriate power mobility device for you is a Group 2 Power Operated Vehicle ideal for persons up to 300 pounds.
The Plan must follow Medicare rules. Medicare rules say that group 2 power wheelchairs are not covered. The requested wheelchair is statutorily not covered. Additionally, your weight is 270 pounds. The requested wheelchair is designed for a weight range of 301-450 pounds. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0807).
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 IRF is the better option for the enrollee's health and faster recovery. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require - or be able to tolerate - 15 hours per week of rehabilitative services with regular physician evaluation. 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: Favorable

We decided that the Plan has to pre-approve facet joint injections with fluoroscopic guidance and moderate sedation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the previous injection was not helpful, and there is no evidence of conservative treatment.
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has lumbar back pain with facet syndrome at L3-L4 and L4-L5. The enrollee reported having pain for years an epidural a couple of years ago and also having had back surgery fusion. There is no evidence of a radicular component to the pain. There is no non-facet pathology to the back pain. The pain has been assessed on a pain scale. The elements of the coverage rule are satisfied. 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 services have been met. Therefore, we decided that the Plan has to pre-approve facet joint injections with fluoroscopic guidance and moderate sedation for the enrollee.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3001).
You asked the Plan to pre-approve foot orthotics. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit for your condition.
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-approve foot orthotics (L3001).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.

You asked the Plan to pre-approve the massage therapy. You say that the massage therapy is to treat migraines. The Plan denied your request. The Plan says massage therapy is not a covered benefit under the member's Evidence of Coverage or under Medicare.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour brand diabetic test strips (A4253).
You asked the Plan to pre-approve the Contour brand diabetic test strips. You say that the plan preferred brand is not as good as Contour so Contour should be covered. The Plan denied your request. The Plan says only Freestyle brand test strips are covered.
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. 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 Contour brand diabetic test strips. Our reviewer says that the Contour test strips are not medically necessary. Our physician reviewer found the medical records submitted do not indicate that the requested strips are medically necessary or reasonable as defined by Medicare rules. 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 Contour brand diabetic test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour brand diabetic test strips (A4253).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (43235).
You asked the Plan to pre-approve an esophagogastroduodenoscopy. You say that this is medically necessary. The Plan denied your request. The Plan says the submitted medical records do not include the results of a colonoscopy.
The Plan follows Medicare rules. Medicare rules say that esophagogastroduodenoscopies are supported for diagnostic purposes for presumed chronic blood loss and for iron deficiency anemia when colonoscopy is negative. 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 an esophagogastroduodenoscopy. Our reviewer says that the requested esophagogastroduodenoscopy is not indicated at this time. Our physician reviewer found the enrollee has unspecified anemia, but the record does not indicate that colonoscopy has been performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an esophagogastroduodenoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (43235).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Alinker walking bike.
You asked the Plan to pre-approve the equipment. You say that your knees have gotten progressively worse by the months. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an Alinker walking bike.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine months of a home ventilator (E0466).
You asked the Plan to pre-approve the home ventilator for nine months. You say that the device is necessary. The Plan denied your request. The Plan says it is appropriate to overturn and allow for three months of the device, but not the nine months billed.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We asked our reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in partially denying the request to pre-approve the home ventilator for nine months. Our reviewer says that the documentation does not show the service is necessary. Our physician reviewer found there is no documented need for the nine months home ventilator (E0466). The Plan was correct to approve three months of the home ventilator, and then additional time can be considered once the need is demonstrated. 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 home ventilator for nine months have not been met. Therefore, we decided that the Plan does not have to pre-approve nine months of a home ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee does not meet the criteria for an admission to a skilled nursing facility.
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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee is an
84-year-old woman with a history of stroke, COPD, hypertension, and vascular dementia, who was admitted to the hospital on May 14, 2021 with acute metabolic encephalopathy and a urinary tract infection. On
May 18, 2021, the enrollee had no complaints, and was in no distress. It was noted that the enrollee could be treated with an oral antibiotic. The enrollee is mostly nonverbal, incontinent, and unable to ambulate. The enrollee has bilateral ankle contractures and is dependent for bed mobility. No required skilled nursing services are identified. While the enrollee may benefit from skilled therapy services, the documentation does not support that such services are required on a daily basis on an inpatient basis in an SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that you need this procedure done to avoid loss of limb. The Plan denied your request. The Plan says you do not meet the NCD criteria for approval.
The Plan must follow Medicare rules. Medicare rules say that you must have a wound that is Wagner grade 3 or higher. You do not have a wound that is Wagner grade III or higher. The service you requested is not necessary under Medicare. We are not able to approve this request We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
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 is too weak to get out of bed on her own. The Plan denied your request. The Plan says the enrollee's needs can be met in a lower level of 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 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 enrollee was discharged back to assisted living facility on May 12, 2021 with home health services and her medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).

You asked the Plan to pre-approve the complete maxillary denture. You say that you need this service to be approved for coverage. The Plan denied your request. The Plan says this service is not covered under 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-approve a complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of an implant body (D6010) for teeth # 22 and 27.

You asked the Plan to pre-approve the dental services. You say that your dentist suggested you have 2 implants placed to stabilize your denture. You say that whenever you wear your denture, it causes so much pain. You say that your denture moves around and does not stay in the same place. You also say that you cannot eat. The Plan denied your request. The Plan says surgical placement of implant body is not listed as a covered service.

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 placement of an implant body (D6010) for teeth # 22 and 27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3020).
You asked the Plan to pre-approve foot orthotics. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit for your condition.
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-approve foot orthotics (L3020).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.
You asked the Plan to pre-approve these services. You say that the treatment is considered safe and effective, as supported by its clinical benefits to patients. The Plan denied your request. The Plan says that a review of the current medical literature indicates that this service is considered experimental and investigational.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Superion spacer remains experimental for use in spinal surgery. More research is needed to show safety and efficacy of the Superion device. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stomach-emptying study for the enrollee.

You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that a same or similar test may have been done.

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 study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the gastric emptying scan ruled out gastroparesis. The possibility of a motility disorder involving the mid and hind gut has not however been addressed as potential contributors to the symptoms, but the medical necessity for a repeat scan is not supported by the available records 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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve a stomach-emptying study for the enrollee.