Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polycarbonate lenses to be provided by your vision provider.
You asked the Plan to pre-approve the polycarbonate lenses. You say that regular plastic lenses are not safe for you because you are very active you play doubles tennis and bike riding, and the lenses can break easily on impact and possibly shatter causing serious eye damage. The Plan denied your request. The Plan says polycarbonate lenses are not covered under your Plan's vision benefit.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Medicare rules say lenses made of polycarbonate or other impact-resistant materials are covered only for beneficiaries with functional vision in only one eye. We looked at the file, the Medicare rules and the Plan's rules. The Plan's eyewear benefit does not cover add-ons except for ultraviolet protection and scratch resistant coating. Medicare rules say lenses made of polycarbonate or other impact-resistant materials are covered only for beneficiaries with functional vision in
only one eye. Therefore, we decided that the Plan does not have to pre-approve polycarbonate lenses to be provided by your vision provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation.
You asked the Plan to pre-approve the bone replacement graft. You say that you believe this service should be
approved for coverage. The Plan denied your request. The Plan says this service is not covered.
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
bone replacement graft for ridge preservation
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on July 7, 2020, to July 9, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you had a hip replacement. You say that you should owe nothing for this. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $1,787.45. The total amount you are being asked to pay is $357.49 ($1,787.45 x 20% = $357.49). The correct coinsurance has been applied to the injection that was provided. An injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on July 7, 2020, to July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 61 additional dialysis visits to be provided by an out-of-network provider.

You asked the Plan to pre-approve the dialysis visits. The Plan denied your request. The Plan says the services are 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 61 additional dialysis visits to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from May 3, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee no longer qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from May 3, 2021, forward.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of congestive heart failure, diabetes, and stroke and is living at home receiving home health physical therapy services for weakness and knee pain. 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. 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 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 IRF admission and services.
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 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 osteomyelitis of the foot and had a transmetatarsal amputation. Medical problems are stable. 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 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 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-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide.
You asked the Plan to pre-approve the aide. You say that this is medically necessary. The Plan denied your request. The Plan says this is requested for custodial care.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 aide. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found the documentation does not clearly establish that the use of a home health aide multiple times a week is reasonable and necessary for the treatment of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the aide have not been met. Therefore, we decided that the Plan does not have to pre-approve a home health aide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and additional accessories for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found while the enrollee may be able to safely operate a power mobility device, the requested K0861 with multiple power options exceeds the enrollee's medical need. The documentation does not specifically and clearly reveal that the enrollee is at high risk for development of a pressure ulcer, or utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. The documentation does not support that it is medically necessary to control the requested power options through the joystick (drive interface). The enrollee's strength and functional ability with independence in eating should be sufficient to control any power options through their own switches. The documentation does not reveal that tilt and recline are 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and additional accessories for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are a
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH services have
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 that the enrollee is was admitted to the hospital due to concern for an infection of an
abdominal wound. There is no documentation provided necessitating admission to a LTACH. 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 they are currently receiving care. There are
no services available at the LTACH that the enrollee requires that are not available at the health care setting
being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve the LTACH services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the insertion of a CardioMEMS device (33289).

You asked the Plan to pre-approve the insertion of a CardioMEMS device. You say that this is medically
necessary. The Plan denied your request. The Plan says that this is experimental.

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 insertion of a CardioMEMS device.
Our reviewer says that the requested services are considered medically reasonable and necessary in this case.
Our physician reviewer found given the enrollee's severe symptoms of recurrent congestive heart failure
(CHF), which appear very sensitive to volume loading conditions, the complexity of the medical regimen, and
the failure to prevent acute CHF hospitalization in this enrollee, the use of the CardioMEMS device is
reasonable and has both clinical data and expert opinion to back up its use in selected appropriate clinical
situations.

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 insertion of a CardioMEMS device have been met. Therefore, we decided
that the Plan has to pre-approve the insertion of a CardioMEMS device (33289).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve micro-invasive glaucoma surgery (0191T).
You asked the Plan to pre-approve glaucoma surgery. You say that this is medically necessary. The Plan denied
your request. The Plan says the enrollee is not on ocular hypotensive medications.
The Plan must follow Medicare rules. Medicare rules say that Medicare considers one iStent, iStent inject, or
Hydrus device per eye medically reasonable and necessary for the treatment of adults with mild or moderate
open-angle glaucoma and a cataract when the individual is currently being treated with an ocular hypotensive
medication and the procedure is being performed in conjunction with cataract surgery.
We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee is
currently being treated with an ocular hypotensive medication. Based on this information, we decided that
Medicare rules for coverage of glaucoma surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve micro-invasive glaucoma surgery (0191T).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 30, 2020.

You asked the Plan to pay for the ambulance services. You say that this was a medical emergency. 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 October 30, 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 October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on November 16, 2020 to November 23, 2020 by an out of network (OON) provider.
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 services were rendered by an out-of-network provider without prior authorization.
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 pay for 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the wound care services provided on November 16, 2020 to November 23, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF
admission.

The Plan must follow Medicare rules. The rules say that an 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 that 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
does require physical and occupational therapy services but does not require an intensive inpatient
rehabilitation therapy program. Additionally, there is concern that the patient will not be able to fully
participate in and benefit from an intensive rehabilitation therapy program provided in an inpatient
rehabilitation facility due to her level of weakness and dependency for transfers and activities of daily living.
Care at the skilled nursing facility level appears to be appropriate in this case.

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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that records show the enrollee does not have need for daily skilled nursing
or daily skilled therapy.
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 reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's 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 for the enrollee.