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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee is at a custodial level of care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve6 physical therapy visits.You asked the Plan to pre-approvethe requested visits. You say that continuing conservative management is the best and safest option.The Plan denied your request. The Plan says 2 visits a week is appropriate for the plan of care.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.The file shows that 8 physical therapy visits were requested from December 26, 2019 to December 31, 2019. The plan 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 the additional requested visits. Our physician reviewer found that the requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was already approved by the health plan. You have had prior therapy for the back and shoulder and continue to be symptomatic. You do not require an additional 6 visits of therapy for the back and shoulder, or to treat a home exercise program for the cervical spine. Services do not need to be only performed by a therapist, or for physical therapy and occupational therapy under the supervision of a therapist. The requested services beyond what was already approved are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's 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 the requested visits have not been met. Therefore, we decided that the Plan does not have to pre-approve6 physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePregabalin.You asked the Plan to pre-approvePregabalin. You say that the medication regimen helps maintain the enrollee's activities of daily living.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.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-approvePregabalin .Benefits for Pregabalinmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.
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 Enbrel.
Benefits for these services 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveQuetiapine.You asked the Plan to pre-approveQuetiapine. You say that the enrollee has been taking Quetiapine with noticeable improvement in symptoms.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.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-approveQuetiapine for the enrollees benefits for Quetiapinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac Sodium 1% gel.You asked the Plan to pre-approve the gel. You say that this is medically necessary.The Plan denied your request. The Plan says this is a medical only policy with the 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 Diclofenac Sodium 1% gel.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel 50mg/mL mini cartridges.You asked the Plan to pre-approve the Enbrel mini cartridges. You say that the enrollee needs this medication.The Plan denied your request. The Plan says this self-injected medication is not covered by Medicare Part B. Part D coverage must be requested.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 Enbrel 50mg/mL mini cartridges.Benefits for the Enbrel mini cartridges 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine 10mg tablet.
You asked the Plan to pre-approve the tablet. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs only.
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 Cyclobenzaprine 10mg tablet.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a limited problem focused oral evaluation (CPT D0140), re-evaluation during a post-operative office visit (CPT D0171), a porcelain/ceramic crown on tooth #8 (CPT D2740), core build-up for tooth #8 (CPT D2950), periodontal scaling and root planing (CPT D4341), gingival irrigation (CPT D4921), an interim partial denture on tooth #9 (CPT D5820), a custom fabricated abutment (CPT D6057), and an abutment supported porcelain/ceramic crown on tooth #9 (CPT D6058).
You asked the Plan to pre-approve the dental limited oral evaluation, the re-evaluation during a post-operative office visit, the porcelain/ceramic crown, the core build-up, the periodontal scaling and root planing, the gingival irrigation, the interim partial denture, the abutment, and the abutment supported porcelain/ceramic crown.. You say that your gums are bleeding, which is causing you pain and discomfort when you eat. You say that you have a loose tooth in the front and it hurts. You say that you cannot wait any longer, and that it is an emergency. The Plan denied your request. The Plan says the services in dispute are not covered benefit under your contract.
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. The type of oral exam you are requesting is not considered a comprehensive or periodic oral exam. The type of denture being requested is an interim denture, which is not listed as a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a limited problem focused oral evaluation (CPT D0140), re-evaluation during a post-operative office visit (CPT D0171), a porcelain/ceramic crown on tooth #8 (CPT D2740), core build-up for tooth #8 (CPT D2950), periodontal scaling and root planing (CPT D4341), gingival irrigation (CPT D4921), an interim partial denture on tooth #9
(CPT D5820), a custom fabricated abutment (CPT D6057), and an abutment supported porcelain/ceramic crown on tooth #9 (CPT D6058).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you cannot go home and take care of yourself. The Plan denied your request. The Plan says that the care you require is custodial in nature.
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 your condition does not meet Medicare criteria for 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 skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that you no longer require skilled therapy and nursing care in an inpatient setting.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 your 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.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve transthoracic echocardiography.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has known CAD and new onset chest discomfort and dyspnea on exertion. His prior echocardiogram two years ago showed preserved LV function but some mitral insufficiency. Given the new onset symptoms of dyspnea and the greater than 2 years since the prior study, reassessment of left ventricular function and cardiac valves is reasonable and necessary and meets criteria for an echocardiographic study. The limited indications which the Health Plan cites (aortic valvular disease or artificial heart valve) for echocardiogram in less than a 3 year time frame are not comprehensive and do not cover all reasonable and appropriate echocardiogram indications as is the case in 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 the services have been met. Therefore, we decided that the Plan has to pre-approve transthoracic echocardiography.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveconsultation and dental extraction to be provided by an oral surgeon.You asked the Planto pre-approvethe oral surgeon services. You say that you need to get this tooth removed and it needs to be done by an oral surgeon due to the positioning.The Plandenied your request. The Plansaysyour dental benefit does not provide coverage for services provided by an oral surgeon.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, only the services of a general dentist are covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approveconsultation and dental extraction to be provided by an oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveParoxetine for the enrollee.You asked the Plan to pre-approveParoxetine. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this medication is not covered under Part B.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-approveParoxetine for the enrollee.Benefits for Paroxetinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehypoglossal nerve stimulation.You asked the Plan to pre-approvethese services. You say that you and your physician feel the services are needed to treat your condition.The Plan denied yourrequest. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that procedure code 0466T is non-covered.The services at issue are hypoglossal nerve stimulation described by procedure code 0466T. This code is non-covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvehypoglossal nerve stimulation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider, for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is available 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 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 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 to an out-of-network provider, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hypoglossal nerve stimulator for the enrollee.
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed, and is intolerant to continuous positive airway pressure. The Plan denied your request. The Plan says the request is not a covered service under Medicare or the enrollee's plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The file shows that a hypoglossal nerve stimulator to treat the enrollee's obstructive sleep apnea was requested for the enrollee. We looked at the file, and Medicare rules. The insertion of a chest wall respiratory sensor electrode (CPT Code 0466T) is non-covered. The rules say that services related to non-covered services are also not covered under Medicare. This means that the procedure as a whole is not covered by Medicare or the enrollee's plan. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a hypoglossal nerve stimulator for the enrollee.
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 would benefit from therapy in the IRF. The Plan denied your request. The Plan says the enrollee does not need an intensive rehab program. Daily skilled therapy in a SNF would be sufficient.
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 enrollee was admitted with strep viridans sepsis and has been receiving IV antibiotics. Her admit diagnoses also include influenza acute infection. She is debilitated, but is now noted to be afebrile and non-toxic. Sepsis and clinical status is improving with proper care. Records do not indicate that there are significant, or complex medical/nursing issues that require frequent physician supervision in the hospital setting. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly minimal assist for functional transfers and ADL's and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says the requested drug is subject to step therapy. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the provided medical records do not indicate that you have tried and failed the required drug. The provided medical records do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects for the 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 the drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Entyvio.
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 this is medically necessary. The Plan denied your request. The Plan says continued acute hospital stay can be offered, until the enrollee can discharge to 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 the enrollee is currently undergoing treatment at an ACH for pulmonary edema and acute renal failure. The enrollee was initially placed on BiPAP and received several rounds of hemodialysis. The enrollee has since been placed on oxygen via nasal cannula and is being monitored for return of renal function. 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 long term care 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.