Persius/hicric huggingface dataset:
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 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 was admitted for dizziness and was treated for a possible cerebellar stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the interspinous spacer device.
You asked the Plan to pre-approve the interspinous spacer device.. You say that you would like reconsideration because this treatment is safe and supported by clinical benefits. The Plan denied your request. The Plan says this device is experimental.
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 interspinous spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its 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 interspinous spacer device. have not been met. Therefore, we decided that the Plan does not have to pre-approve the interspinous spacer device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two crowns (D2750 x2).
You asked the Plan to pre-approve the crowns.. You say that tooth #'s 24 and 25 are fractured on the incisal, and are very worn out which makes the teeth weak. The Plan denied your request. The Plan says the crown benefit has a limit to two in a calendar year. The Plan also says that this request has gone over this limit for the 2020 Plan year.
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, crowns are limited to 2 of either codes D2750, D2751, or D2752 per calendar year. The record shows that the enrollee received two crowns (D2750 x2) on November 4, 2020, and the enrollee's crowns benefit had been exhausted for the 2020 Plan year. Therefore, we decided that the Plan does not have to pre-approve two crowns (D2750 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a negative pressure wound therapy pump (NPWT).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the device has been approved for the prior 7 months.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates that you have a deep stage IV wound on your tailbone area. The record sent by the provider indicates a deep stage IV wound on the tailbone area that has been treated with wound VAC NPWT for several months. The plan has approved seven consecutive months of the pump for the wound. There is another different wound on your left hip that is treated with a dressing changed every 1-2 days. The records regarding the measurements and request for the wound VAC suction device reference the deep tailbone (left ischium and coccyx) wound areas, not the left hip wound. The review indicates that under Medicare guidelines, the request for continued wound VAC NPWT pump therapy on the coccyx and ischium wound is not medically necessary because the records show that you have been using the wound VAC NPWT device for greater than 4 months on this tailbone area wound; in fact, the device has been approved for the prior 7 months. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a negative pressure wound therapy pump (NPWT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a gastroenterology office visit. You say that you want to see another gastroenterologist who can perform a colonoscopy under total sedation. The Plan denied your request. The Plan says the provider is out of network and the requested office visit has been approved with an in-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 medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) dermatologist.
You asked the Plan to pre-approve the out of network dermatology care. You say that you would like to see this provider because you had been treated by them for a number of years. You trust this provider and they are aware of your medical history. The Plan denied your request. The Plan says they do not cover out of network care except in limited circumstances. The provider in question is not in the Plan's network, and the requested services are routine follow-up care. These services can be provided 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 the medical services to be provided by an out of network (OON) dermatologist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care for the enrollee.

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 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 reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing (SN) 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. The enrollee has no complex wound care or other SN need. The enrollee's 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 nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a SNF 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee has a wheeze in her chest when breathing and runs out of breath quickly and you want to find out why. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria because the member is not asymptomatic and medical records do not document that the member has tobacco smoking history of 30 pack-years.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. 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 for the low dose computed tomography (LDCT) scan for lung cancer screening. Our reviewer says that based on the medical records provided, there is no documentation that the low dose lung cancer screening chest CT scan is medically reasonable and necessary as records do not document a 30-pack year smoking history and the enrollee is not asymptomatic. Other diagnostic testing may be indicated to evaluate the enrollee's pulmonary symptoms as determined by her medical care provider. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee arthroscopy (29870).
You asked the Plan to pre-approve Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) (29870). You say that the enrollee is very symptomatic and having severe pain. The Plan denied your request. The Plan says the MRI result is inconclusive.
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 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) (29870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for knee surgery not met. There is no imaging study that shows surgical pathology. Surgery is not necessary based on the current imaging studies. There are no red flags for surgery at this time. There is no correlation between imaging and a diagnosis for surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) (29870) have not been met. Therefore, we decided that the Plan does not have to pre-approve knee arthroscopy (29870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment and an abutment supported porcelain fused to metal crown.
You asked the Plan to pre-approve the custom fabricated abutment and abutment supported crown. You say that your provider recommends these services. The Plan denied your request. The Plan says these services are excluded from coverage.
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 custom fabricated abutment and an abutment supported porcelain fused to metal crown.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral formula.
You asked the Plan to pre-approve the formula. You say that this is medically necessary. The Plan denied your request. The Plan says there is no benefit for supplements that are taken by mouth.
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 formula. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found per plan policy and Medicare guidelines, enteral feeding when given via a feeding tube may be covered with a permanent (over 3 months with no chance of recovery) GI tract dysfunction. Plan guidelines clearly state that enteral nutrition products when administered orally are NOT a covered benefit. The review has determined that the enrollee does not meet the criteria for this request. 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 formula have not been met. Therefore, we decided that the Plan does not have to pre-approve enteral formula.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits and services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve out of network care. You say that you want to be able to continue seeing your current pulmonologist. The Plan denied your request. The Plan says they do not cover out of network services, except in limited circumstances. The requested services are not urgent and can be provided by an in-network specialist. The care requested is not an active treatment plan. Routine follow-up care can safely be transitioned to an in-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 visits and services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.
You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870).
You say that the enrollee needs this procedure. The Plan denied your request. The Plan says 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 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of interspinous process distraction devices. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve an onabotulinumtoxina (Botox) injection.
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says that the enrollee has not failed an anticholinergic medication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Botox. Our physician reviewer found that the enrollee has a history of medically refractory overactive bladder that has been treated with Botox injections in the past, but more recently with neuromodulation in 2015. Current symptoms include urgency and urge incontinence. The enrollee lost over 100 pounds of weight and her interstim lead became dislodged, which is causing pain and no longer effective. Botox is FDA-approved and indicated for the enrollee's diagnosis of medically refractory overactive bladder. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have been met. Therefore, we decided that the Plan has to pre-approve an onabotulinumtoxina (Botox) injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous lysis of adhesions 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 the requested procedure is not considered experimental, investigational, or unproven.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found percutaneous lysis of adhesions remains experimental for the treatment of chronic low back pain. More research is needed to show the safety and efficacy of the procedure. It is not likely to be effective in this patient with complex degenerative lumbar spine condition. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous lysis of adhesions for the enrollee.