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

We decided that the Plan does not have to pre-approve a transfer from one hospital to another.
You asked the Plan to pre-approve the requested transfer. You say that the enrollee has failed guideline directed medical therapy. The Plan denied your request. The Plan says there is no advantage in moving the enrollee from the current acute care.
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 requested transfer. Our physician reviewer found that the enrollee was admitted to the acute hospital for dyspnea and new onset atrial fibrillation requiring intravenous dobutamine, cardioversion, diuresis, and monitoring. The enrollee does not require services at the requested inpatient hospital that are not already available at the current acute care hospital. Transfer to the acute care hospital would not be medically necessary for the diagnosis and condition of this enrollee as there is no benefit in comparison to currently available care to suggest there would be an improvement in overall outcome as a result of this transfer.
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 requested transfer have not been met. Therefore, we decided that the Plan does not have to pre-approve a transfer from one hospital to another.
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 pulmonary and physical rehab offerings are not available in his current short-term acute care setting. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care.
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 physician reviewer found that the enrollee was admitted to the current acute care hospital with pulmonary edema, cardiomegaly, hypoxia, and respiratory failure requiring BiPAP and then intubation. He was treated with antibiotics for pneumonia and later required trach and PEG. Recent notes show worsening x-ray. The enrollee appears to be unstable and requires additional short-term acute care services in order to stabilize and complete treatment, which can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650, L8680).
You asked the Plan to pre-approve a spinal cord stimulator. You say that you are in pain. The Plan denied your request. The Plan says records from the psychological evaluation that you were referred for have not been received.
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. Such screening must include a psychological evaluation. The file does not show that a psychological evaluation has been conducted in conjunction with this request for a spinal cord stimulator trial. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator (63650, L8680).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that your broken femur needs to be fixed. The Plan denied your request. The Plan says there are in-network providers that can provide the service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 neurology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 Day Reader (K0554) and Sensor (K0553)
You asked the Plan to pre-approve the FreeStyle Libre 14 Day Reader and Sensor. You say that you would like the FreeStyle Libre 14 Day Reader and Sensor to be approved for coverage. The Plan denied your request. The Plan says the records do not show that you are using multiple injections of insulin on a daily basis.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the FreeStyle Libre 14 Day Reader and Sensor have not been met.
Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 14 Day Reader (K0554) and Sensor (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated abutment - includes modification and
placement (D6056), bone replacement graft for ridge preservation - per site (D7953), and surgical placement of
implant body: endosteal implant (D6010).
You asked the Plan to pre-approve a prefabricated abutment, bone replacement graft and endosteal implant.
You say that the services are medically necessary for your well-being and health. The Plan denied your request.
The Plan says these services are not covered under Medicare or your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
prefabricated abutment - includes modification and placement (D6056), bone replacement graft for ridge
preservation - per site (D7953), and surgical placement of implant body: endosteal implant (D6010).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the 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 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 appears to be more unstable and requires additional short-term acute care
services in order to complete treatment including weaning and stabilization of pleural effusions and respiratory
status which can be safely administered at the current facility. The enrollee does not require services at the
LTACH that are not already available and covered at the current facility. There are no services at the LTACH
that the enrollee requires that are not already available and covered at the current facility. Therefore, this
request for LTACH services will be considered not medically necessary at this time. Transfer may be
considered when treatment has completed and the enrollee more stable including long-term enteral feeding
support in place, which is currently on hold.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network surgical oncology consultation.
You asked the Plan to pre-approve the surgical oncology consultation. You say that you were diagnosed with
cancer and need a second opinion to make a decision about the treatment. The Plan denied your request. The
Plan says the service requested can be safely rendered in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an out-of-network surgical oncology consultation.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says that the stay 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 SNF care. Our physician reviewer found the enrollee does qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee has right side weakness at baseline and now has a left arm injury. Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, cannot be provided 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that this item is medically necessary. The Plan denied your request. The Plan says this request is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says that the member must receive care from a network provider. In most cases, care the member receives from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. The member's Evidence of Coverage states care will be directed outside of the primary network only if it has been determined that they cannot provide the necessary care to the member.
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 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 physical therapy services to be provided by the requested out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services.
You asked the Plan to pre-approve the inpatient mental health services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health services. Our reviewer says that the inpatient mental health services are not medically necessary. Our physician reviewer
found the enrollee does not require inpatient mental health treatment beyond the last covered date, as he is not a danger to himself or others and does not have any delusions, auditory, or visual hallucinations. 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 inpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health 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 enrollee needs LTACH services. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
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 there is no evidence that the enrollee requires services that are not currently available. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (D4261), guided tissue regeneration (D4266), an unspecified periodontal procedure (D4999) and an unspecified oral surgery procedure (D7999).
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered under your dental benefit under any circumstances.
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 osseous surgery (D4261), guided tissue regeneration (D4266), an unspecified periodontal procedure (D4999) and an unspecified oral surgery procedure (D7999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arch supports.
You asked the Plan to pre-approve the arch supports. You say that you have tried some over-the-counter brands of orthotics and they don't work well or give you the support you need. You say that you are in pain and would like to start walking and to be able to work out again. You say that you have big feet and that you need to take care of yourself. 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-approve arch supports.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with an out-of-network urologist.
You asked the Plan to pre-approve the office visit. You say that you want one follow up visit to discuss your prostatectomy, PSA and medication. You say that you will transfer to an in-network urologist after this visit. The Plan denied your request. The Plan says you must receive your care from a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit with an out-of-network urologist.
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 health plan's denial should be upheld. You do not require the intensity of services
provided at an IRF. Specifically, you are not shown to be able to tolerate fifteen (15) hours per week of
rehabilitative services with regular physician evaluation. Your 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two doses of 32 units each of Zilretta.
You asked the Plan to pre-approve Zilretta. The Plan denied your request. The Plan says the dose being requested is not approved by the Food and Drug Administration (FDA).
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that Zilretta is not medically reasonable and necessary for the enrollee. Our physician reviewer found the medical records show that the enrollee has already had bilateral Zilretta injections in the knees. Our reviewer also found that the FDA has not approved Zilretta for repeat knee injection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve two doses of 32 units each of Zilretta.