Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6065) 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 this 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 dental services (D6065) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour next test strips (CPT Code A4253).
You asked the Plan to pre-approve the strips. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says you must try and fail a preferred glucose test strip/disk product that is covered by your Medicare Advantage plan. The Plan states you may not have to try these products if your prescriber states that you cannot use these products for medical reasons and the preferred products that are covered by your plan include:-One Touch. The Plan states you did not meet the criteria.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the strips have not been met. Criteria also require the prescriber has provided documentation indicating the patient has failed the preferred diabetic testing supply product, unless documentation is provided that indicates the patient has limitations of use (e.g., visual impairment and physical or mental limitations) to the preferred glucose test strip/disk product. Review of the records do not show that you meet the criteria for this brand of test strip. You have not tried and failed the OneTouch Test strips and you have no limitations of use to the preferred product. Therefore, we decided that the Plan does not have to pre-approve Contour next test strips (CPT Code A4253).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One 30 mg/3 mL syringe injection.
You asked the Plan to pre-approve Gel-One. You say that this requested service is medically necessary. The Plan denied your request. The Plan says rules for coverage of the requested drug have not been met.
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 Gel-One. Our reviewer says that this service is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 70-year-old male with osteoarthritis of the knee. The enrollee must have had an inadequate response to an aspiration (a procedure in which fluid is removed from the knee joint) and also an injection of intra-articular steroids (these are a different group of drugs used to treat inflammation and pain). In this case, the member's provider did not document or report that this activity or therapy has occurred. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One 30 mg/3 mL syringe injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture, bone replacement graft, and gingival irritation.
You asked the Plan to pre-approve these services. You say that the services should be considered real dental necessities. The Plan denied your request. The Plan says the services are not covered.
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 cone beam computed tomography (CT) capture, bone replacement graft, and gingival irritation.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician or nursing supervision in an IRF. While you may benefit and participate in multiple therapies your functional level and activity tolerance does not require therapy on an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: 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 enrollee still needs assistance. The
Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.
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 does not require services at the LTACH that are not already available at
the current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that
are not already available and covered at the current facility. Our physician reviewer also found that transfer to a
lower level of care may be considered when appropriate and when treatment has completed.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the
enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent
basis on an outpatient basis, in a long-term care facility, or in the home with home health care services.
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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that this shower chair is used for safety reasons. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate 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 a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is very important for the enrollee. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says the visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. The file shows that 10 physical therapy visits were requested. The Plan has agreed to pre-approve 2 visits. 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 additional services. Our physician reviewer found that the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. She has had prior therapy for this condition. The documentation does not indicate that her functional level requires the unique skills of a professional therapist to provide treatment, that the services can be performed only by a therapist, or under the supervision of a therapist. The enrollee was approved for 2 more visits to ensure competence in a home exercise program. The requested services are not part of a maintenance program. The specialized skill of a qualified therapist is not required to deliver a program to maintain her current condition, or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the residential treatment, alcohol and/or drug services, subacute detoxification (H0018) provided on July 27, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the residential treatment. You say that there was no time to submit a prior authorization. You are being billed over $30,000 for these services and you were under the impression that they were all paid for. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 had network providers available who could have provided 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 the residential treatment, alcohol and/or drug services, subacute detoxification (H0018) provided on July 27, 2020 by an out of network (OON) provider.
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 requires this level of care. The Plan
denied your request. The Plan says criteria for IRF care are not met in this case.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the patient was admitted for cardiac arrest. Medical conditions are stable. There are
no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The
patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There
is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee prostheses flexible protective outer surface covering systems.
You asked the Plan to pre-approve flexible protective outer surface covering systems (L5962). You say that the enrollee needs the flexible protective outer surface covering systems (L5962). The Plan denied your request. The Plan says there is no clinical information that indicates the enrollee lives in an unusually harsh environmental situation.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file and Medicare rules. There is no documentation to support that the enrollee has special needs for protection against unusually harsh environmental situations. Based on this information, we decided that Medicare rules for coverage of flexible protective outer surface covering systems (L5962) have not been met. Therefore, we decided that the Plan does not have to pre-approve knee prostheses flexible protective outer surface covering systems.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ogivri for Solution 420MG (CPT Code Q5114).
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee is receiving Ogivri in combination with carboplatin and paclitaxel (other cancer fighting drugs).
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 medication. Our physician reviewer found OGIVRI for Solution 420MG (CPT Code Q5114) is not FDA-approved for the enrollee's diagnosis. Approved for combination therapy with carboplatin and paclitaxel for serous uterine cancers with HER2 expression and then with continued maintenance. This enrollee completed chemotherapy for recurrent disease in December 2020. Phase II trial with trastuzumab used in combination with chemotherapy and then maintenance. 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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Ogivri for Solution 420MG (CPT Code Q5114).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not supported by the compendia.
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 Opdivo. Our reviewer says that Opdivo is not FDA-approved for treatment of urothelial cancer. Our physician reviewer found the Medicare-approved compendia do not sufficiently support use of Opdivo in the treatment of urothelial 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 Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a sleep appliance out-of-network.
You asked the Plan to pre-approve the appliance. You say that the network provider is not a dentist and a DME supplier. The Plan denied your request. The Plan says there are network providers available.
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 a referral for a sleep appliance out-of-network.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve total electric hospital bed. You say that you need this bed due to your condition. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because a total electric hospital bed is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of total electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.