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

We decided that the Plan does not have to pre-approvecontinuation of SNF care provided from December 25, 2020, forward.You asked the Plan to pre-approveSNF 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no required skilled nursing needs are identified at this time. The documentation does not support that skilled services on a daily basis are medically reasonable and necessary at this time.We looked at this physician'sreview, 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-approvecontinuation of SNF care provided from December 25, 2020, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesensors for Freestyle Libre the CGM.You asked the Plan to pre-approvethe DME. You say that the member uses one (1) sensor every fourteen (14) days.The Plan denied your request. The Plan says this is not reasonable and medically necessary as the member is not on frequent short acting insulin injections based on BG readings.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The most recent records from the physician indicate that the member is not on any insulin. Therefore, a continuous glucose monitor is not reasonable and necessary and will not be covered by the member's insurance.Therefore, we decided that the Plan does not have to pre-approvesensors for Freestyle Libre the CGM.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental consultation and extraction to be performed by an oral surgeon.You asked the Plan to pre-approvethe dental services. You say that the services are necessary.The Plan denied your request. The Plan says the services are not covered when performed 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, the requested items or services are not among those covered under this benefit. The health plancontract says limitations/restrictions: services must be performed by a participating general dentist.Therefore, we decided that the Plan does not have to pre-approvedental consultation and extraction to be performed by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a perforated stomach ulcer. 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-approveacute IRF admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by a provider that opted out of Medicare.You asked the Plan to pre-approvethe medical services. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the services are not approved.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal would be provided in anon-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by a provider that opted out of Medicare.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a penile implant. 
 
You asked the Plan to pre-approve a penile implant. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee has not tried enough other treatments. 
 
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 penile implant. Our reviewer says that 
the requested implant is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records do not indicate that the enrollee has tried and failed any secondary 
treatment options such as vacuum erection device, medicine through the urethra, or medicine, injected into the 
penis. 
 
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 penile implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a penile implant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery; complex (CPT Code 77525). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 service. Our physician reviewer 
found the Medicare criteria have not been met. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton treatment delivery; complex (CPT Code 77525).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
December 18, 2020. 
 
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee is not safe to be 
discharged at this time. The Plan denied your request. The Plan says the enrollee no longer requires daily 
skilled 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 continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 87-year-
old female with dementia and a recent hip fracture requiring surgery. From a nursing perspective, the 
beneficiary received oral medications.  The beneficiary had stable vital signs. She was treated for pain with 
effect. Her lungs were clear.  She had IVF ordered but pulled out her IV.  
 
 
Regarding rehabilitation services, the beneficiary received PT, ST and OT in the SNF.  By the dates in 
question, the beneficiary was at a maximal assist level with functional bed mobility and transfers.  The 
beneficiary required varying assist with ADLs. She was alert with confusion. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
This beneficiary 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care beyond December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a Pulmonologist without a referral 
from your primary care provider (PCP). 
 
You asked the Plan to pre-approve an office visit with a Pulmonologist without a referral from your PCP. 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. Medicare rules say that a Medicare plan may restrict members to a 
network of providers as long as medically necessary covered care is accessible and available through this 
network.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an office visit with a Pulmonologist without a referral from your PCP have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an office visit with a Pulmonologist without a 
referral from your primary care provider (PCP).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical 
assessment in the case file does not support that the enrollee in this case is reasonably expected to benefit from, 
and improve with, LTACH services. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 the patient appears to be more stable, however, they appear to require short term 
additional acute care services to further stabilize which can be safely completed at the current facility. The 
patient does not require services at the LTACH that are not already available at the current facility. There are 
no services at the LTACH that the patient requires that are not already available and covered at the current 
facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. 
Transfer to a lower level of care can be considered soon. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Regranex. 
 
You asked the Plan to pre-approve Regranex. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Regranex.  
 
Benefits for Regranex 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (interlaminar 
approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, 
facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single 
or multiple levels, unilateral or bilateral; lumbar (CPT Code 0275T). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 service have not been met. Medicare rules state that this is 
covered if the member is enrolled in an approved clinical study for lumbar spinal stenosis. There is no evidence 
that the member is enrolled in a clinical study. Therefore, we decided that the Plan does not have to pre-
approve percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, 
(with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under 
indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar (CPT 
Code 0275T).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Musculoskeletal Surgery (CPT Code(s): 22869, 22612, 22867, 22870) for the enrollee.

You asked the Plan to pre-approve this surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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 this surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the distraction device requested is  experimental as more research is needed to show safety and efficacy. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Musculoskeletal Surgery (CPT Code(s): 22869, 22612, 22867, 22870) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGammagard liquid immune globulin infusion (J1569).You asked the Plan to pre-approveGammagard liquid immune globulin infusion. You say that this treatment is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says this service is not covered by Medicare for the enrollee's condition.The Plan follows Medicare rules. Medicare rules say that Intravenous immune globulin (IVIG) may be indicated for MG. Routine use is not indicated. IVIG may be considered in patients with severe MG to treat acute severe decompensation when other treatments have been unsuccessful or are contraindicated.We asked our physician reviewer to carefully review the case file andapply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gammagard liquid immune globulin infusion. Our reviewer says that Gammagard liquid immune globulin infusion is not medically necessary at this time. Our physician reviewer found the documentation does not support that the enrollee has severe MG with acute severe decompensation, and that other treatments have been unsuccessful or are contraindicated.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gammagard liquid immune globulin infusion have not been met. Therefore, we decided that the Plan does not have to pre-approveGammagard liquid immune globulin infusion (J1569).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that you would benefit from a skilled nursing facility stay.The Plan denied your request. The Plan says you only require custodial 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require daily skilled nursing services. The documentation does not support that skilled therapy services are needed on a daily 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Watchman device (a device implanted in the heart for stroke prevention) and hospital inpatient admission with an out-of-network provider.

You asked the Plan to pre-approve the services. You say that the services are necessary.The Plan denied your request. The Plan says the services are not 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is insufficient to demonstrate that the coverage criteria established by the NCD have been met in this case (in regard to the provider performing the procedure and the registry).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 Watchman device (a device implanted in the heart for stroke prevention) and hospital inpatient admission with an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81407, 81479, 81286, 81408 and 81404) provided on June 1, 2020. You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomaticpatients with suspected or documented cardiovascular disease. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (81407, 81479, 81286, 81408 and 81404) provided on June 1, 2020.