Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with/without wheels (E0118).
You asked the Plan to pre-approve a crutch substitute. You say that this item is medically necessary The Plan denied your request. The Plan says there is insufficient published clinical literature that demonstrate the safety and efficacy of this item.
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 crutch substitute. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, you were diagnosed with Achilles tendinitis of the left leg. The provided records were limited and did not sufficiently discuss any reasoning as to why crutches or a walking boot would not be appropriate for this patient to support 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 a crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with/without wheels (E0118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a deep medicated filling in tooth #20 (D3110).

You asked the Plan to pre-approve dental service. You say that you have been taking antibiotics but still have pain, so this procedure is necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is not covered by the Plan's dental benefits.

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 deep medicated filling in tooth #20 (D3110).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lantus Solos.
You asked the Plan to pre-approve Lantus Solos. 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 Lantus Solos.
Benefits for Lantus Solos 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dynamic adjustable wrist extension / flexion device (E1805), dynamic adjustable elbow extension/flexion device (E1800), elbow orthosis (L3761), and hand finger orthosis (L3924).
You asked the Plan to pre-approve the dynamic adjustable wrist extension / flexion device, dynamic adjustable elbow extension/flexion device, elbow orthosis, and hand finger orthosis. You say that the orthoses are medically necessary. The Plan denied your request. The Plan says the requested orthoses have not been shown to be medically effective in the enrollee's situation.
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 dynamic adjustable wrist extension / flexion device, dynamic adjustable elbow extension/flexion device, elbow orthosis, and hand finger orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has contractures from an old stroke. There is no documentation of recent change in condition. The enrollee can only move the upper arm passively. The provided medical records do not demonstrate the medical reasonableness or necessity of the requested services. Therefore, the requested services are not recommended. 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 dynamic adjustable wrist extension / flexion device, dynamic adjustable elbow extension/flexion device, elbow orthosis, and hand finger orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the dynamic adjustable wrist extension / flexion device (E1805), dynamic adjustable elbow extension/flexion device (E1800), elbow orthosis (L3761), and hand finger orthosis (L3924).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF 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 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 congestive heart failure, respiratory failure and interstitial lung disease. 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, and 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. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy (CPT code 90837) to be provided by an
out-of-network provider.
You asked the Plan to pre-approve the services. You say that the provider requested an exclusion to be able to
provider your services as an out-of-network provider. The Plan denied your request. The Plan says your
provider needs to be a part of your plan for us to approve of this service unless the service is an emergency.
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
psychotherapy (CPT code 90837) to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's care is not complex and does not require intensive daily therapy.
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 physician reviewer found that you are at a moderate to maximal assist level for standing up, moderate assist for walking using a rolling walker, minimal assist for feeding, total assist for bathing and toileting, and maximal assist for toilet transfer. You do not require the intensity of services provided at an IRF. Specifically, you are 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia IV.
You asked the Plan to pre-approve Orencia IV. The Plan denied your request. The Plan says the enrollee has not tried and failed Inflectra or Remicade, and Simponi Aria.
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 Orencia IV. Our physician reviewer found that the enrollee has Rheumatoid arthritis. The Plan requires a trial of Inflectra or Remicade, and Simponi Aria before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective, 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 Orencia IV have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia IV.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endosteal implants for teeth #6, 7, 11, 13 (D6010).
You asked the Plan to pre-approve the services. You say that you need this as soon as possible. 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 endosteal implants for teeth #6, 7, 11, 13 (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a protective outer surface covering.
You asked the Plan to pre-approve the requested item. You say that this is what the enrollee has been wearing in the past. The Plan denied your request. The Plan says the enrollee's activity does not subject his prothesis to hard environmental situations.
The Plan must follow Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain medical indications.
We looked at the file and Medicare rules. The records provided do not show that the enrollee needs protection against unusually harsh environmental situations. The records do not show that the enrollee requires extra protection beyond what the approved covering can provide. Based on this information, we decided that Medicare rules for coverage of the requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a protective outer surface covering.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
You asked the Plan to pre-approve continued services. You say that the enrollee's complex issues should be considered. The Plan denied your request. The Plan says the enrollee does not have acute symptoms that require 24-hour inpatient care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services from March 18, 2021, forward were requested. 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 continued services. Our physician reviewer found that the enrollee with anxiety, depression and eating disorder was receiving inpatient psychiatric services. She is taking her medications, without side effects and no medication adjustments are being made. There were no suicidal ideations, homicidal ideation, or hallucinations. She was independent in her activities of daily living. There is no evidence of medical instability. She did not exhibit an acute condition requiring 24-hour care. Therefore, inpatient psychiatric services from March 18, 2021 forward are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939).
You asked the Plan to pre-approve the bone marrow aspirate. You say that the bone marrow aspirate is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the request for bone marrow aspirate is not medically 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 bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the lumbar surgery performed. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. Therefore, the request for bone marrow aspirate is not medically reasonable and necessary for the approved lumbar fusion. 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve the bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins when required (CPT code D2950), for the enrollee.
You asked the Plan to pre-approve the dental services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve core buildup, including any pins when required (CPT code D2950), for the enrollee.
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 the enrollee can be safely treated in the current setting.

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 receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses (L1851) provided November 12, 2020.
You asked the Plan to pay for the knee orthoses. You say that this request was medically necessary. The Plan denied your request. The Plan says the request did not include a proof of delivery or delivery ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery. In this case, there is no proof of delivery in the request. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthoses (L1851) provided November 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that the enrollee's strength is weakening. The Plan denied your request. The Plan says the enrollee is not medically stable.
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 services. Our physician reviewer found that there is documentation that the enrollee requires skilled nursing services. However, there is legitimate concern about the stability of the enrollee's condition for transfer out of the acute hospital due to the worsening renal function and the symptomatic orthostatic hypotension. Therefore, the requested SNF services are not medically reasonable and 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on September 22, 2020.

You asked the Plan to pay for the lab testing. The Plan denied your request. The Plan says there is no evidence of a relationship with the enrollee and the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician who is treating the beneficiary. 

The file shows that a Covid-19 test was provided. We looked at the file and the rules. In this case, there are insufficient medical records to show that the testing was ordered based on the enrollee's clinical history, signs, and/or symptoms. There are no records that show the physician was treating the enrollee for a specific medical problem and who uses the results in the management of the enrollee's specific medical problem. 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 pay for the lab testing provided on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic medial branch blocks.

You asked the Plan to pre-approve the diagnostic medial branch blocks. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the requested procedure does not help with groin pain and cannot be authorized.

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 diagnostic medial branch blocks. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation shows that the member's pain radiates, which does not meet LCD criteria for coverage.

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 diagnostic medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic medial branch blocks.