Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Posterior Interspinous Decompression Spacer.

You asked the Plan to pre-approve a Posterior Interspinous Decompression Spacer. You say that the enrollee
has been suffering from this debilitating disease and experiencing symptoms of lumbar spinal stenosis. You say
that the enrollee's quality of daily living has been greatly affected and his normal daily activities are disrupted.
You say that the enrollee has lost independence and there is a potential for a decrease in overall health status,
due to the resultant sedentary levels of activity. The Plan denied your request. The Plan says the requested
procedure is considered investigational and is not covered by Medicare.

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 a Posterior Interspinous Decompression
Spacer. Our reviewer says that a Posterior Interspinous Decompression Spacer is not considered medically
reasonable and necessary in this case. Our physician reviewer found this is an experimental and investigational
procedure. There are no head-to-head comparison studies with the standard therapy of surgical decompression.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Posterior Interspinous Decompression Spacer have not been met. Therefore,
we decided that the Plan does not have to pre-approve a Posterior Interspinous Decompression Spacer.
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 care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for abscess of the right foot. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan rendered on September 3, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 pay for the duplex scan rendered on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up for tooth 31.
You asked the Plan to pre-approve core build up (D2950). You say that the enrollee needs this procedure. 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 core build up for tooth 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tooth extractions (D7210).

You asked the Plan to pre-approve tooth extractions. You say that the member has an infection and abscess and needs the extractions as soon as possible. The Plan denied your request. The Plan says 10 surgical removals of erupted teeth were requested requiring removal of bone and/or sectioning of teeth, and including elevation of mucoperiosteal flap if indicated. The plan allows for 2 extractions per year. The member's benefit has been exhausted for the 2021 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. The Plan covers two extractions per year. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of tooth extractions have not been met. Specifically, the enrollee has exhausted the benefit limit for tooth extractions in the 2021 Plan year. Therefore, we decided that the Plan does not have to pre-approve tooth extractions (D7210 x10) for teeth numbers 4-12 and 16.
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 service is medically necessary. The Plan denied
your request. The Plan says you can benefit from services provided at 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 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 complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care and you do not require an
intensive inpatient rehabilitation therapy program.

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. Specifically, you can receive services at a lower
level of care. This means admission to an IRF is not medically necessary or reasonable. Therefore, we decided
that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp injections and Nplate (romiplostim) injections.
You asked the Plan to pre-approve the Aranesp and Nplate injections. You say that these drugs should be covered. The Plan denied your request. The Plan says the criteria for coverage of these drugs are not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Aranesp and Nplate injections. Our reviewer says that neither of the requested drugs are considered reasonable and necessary in this case. For Aranesp, this is due to step therapy criteria not being met. Our physician reviewer found the patient has not tried Retacrit, the plan preferred drug, and has no contraindications to Retacrit. Retacrit is likely to be as effective as Aranesp. Regarding Nplate, the patient has platelets over 50 and has not tried other means to increase his platelets. Platelets at this level should be adequate, and if felt to be autoimmune, a trial of steroids
would be first line. 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 Aranesp and Nplate injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp injections and Nplate (romiplostim) injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa.

You asked the Plan to pre-approve Vascepa. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vascepa.

Benefits for Vascepa may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 17, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 17, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz tab 5mg.
You asked the Plan to pre-approve the tab. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as a benefit exclusion.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xeljanz tab 5mg.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital services.

You asked the Plan to waive the copayments for inpatient hospital services. You say that the enrollee should not have any responsibility for claims pertaining to a COVID-19 diagnosis hospital stay. The Plan denied your request. The Plan says you were charged this coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $215 copayment each day for days 1-7 of a covered inpatient stay for Inpatient Hospital Care.

The enrollee has been asked to pay a $215 copayment each day for days 1-7 of a covered inpatient stay for inpatient hospital services. Inpatient hospital services fall within the Inpatient Hospital Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for inpatient hospital services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says benefits can be received at 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 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 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. Specifically, benefits can be received at a lower level of care. This means admission to an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast.

You asked the Plan to pre-approve the MRI. You say that the records provided support the need for the requested breast MRI. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of a breast MRI.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was treated with antibiotics which had been helping with breast pain, but the patient feels "something within the breast" even after treatment. MRI of the breast was requested. Breast imaging for lumps begins with mammogram or ultrasound depending on the history. An MRI in this case would not be appropriate as first line imaging was not used yet. The requested breast MRI is not considered 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 you are currently undergoing treatment at an acute care hospital (ACH) for a chronic knee infection. You are not intubated/ventilated. There is no evidence that you require 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 you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing subacute or long term care (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: 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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 23, 2021 with pneumonia and sepsis. The physical therapy note on March 3, 2021 states she needs modified assist to sit up and minimal assist to stand up, ambulate to chair, and sit down. The records do not support that she requires the intensity of services in an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 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: Unfavorable

We decided that the Plan does not have to pre-approve a chiropractic office visit.

You asked the Plan to pre-approve the visit. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of subluxation of the spine.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve a chiropractic office visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement prosthetic leg with an advanced foot (L5981 Flex Foot system with L5968 Multi-Axial Ankle).

You asked the Plan to pre-approve the replacement prosthetic leg with an advanced foot. You say that you are a highly active user and due to this, have greater than normal prosthetic demands. You say that this means that you will have a need for a new prosthesis more often than the lower level users due to higher wear on the prosthesis with normal use. The Plan denied your request. The Plan says the criteria for coverage of the requested prosthesis has not been met as the device is not reasonable and necessary.

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 replacement prosthetic leg with an advanced foot. Our reviewer says that the replacement prosthetic leg with an advanced foot is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in this case does not support that a new prosthetic foot and ankle are medically reasonable and necessary, as there is no irreparable damage to the foot and ankle. The notes do not demonstrate that the enrollee's current foot and ankle cannot be used with a new socket. This request for a new prosthesis exceeds the enrollee's functional need, and consequently does not meet Medicare reasonable and necessary criteria. 

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 replacement prosthetic leg with an advanced foot have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement prosthetic leg with an advanced foot (L5981 Flex Foot system with L5968 Multi-Axial Ankle).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown and core build up.
You asked the Plan to pre-approve a crown and core build up. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 a crown and core build up.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan colonography for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says request for overturn of a specifically non-covered benefit cannot be granted.

The Plan must follow Medicare rules. The rules say that screening computed tomographic colonography (CTC)
is not covered.

The requested scan is not covered at this time. Based on this information, we decided that Medicare rules for
coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT
scan colonography for the enrollee.