Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the enrollee's medical problems are still acute.
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 physician reviewer found that the enrollee presented to the current acute care hospital for planned surgical exploration and repair for recurrent bowel obstruction which required two surgeries during the stay and was complicated by sepsis and respiratory failure. The enrollee appears to be worsening and unstable. She requires additional short-term acute care services which can safely be received at the current facility. She does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary as there is no advantage to transfer 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve therapeutic CGM. You say that the enrollee has some cognitive issues and this device has been the most effective way of managing her hypoglycemic episodes. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic CGM.

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 therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenetic testing provided on February 22, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the limited records from the testing lab facility do not support that the pharmacogenetic testing was medically necessary for the enrollee's unique clinical scenario. The information submitted does not confirm that Medicare coverage criteria have been met. The limited records provided do not support that these tests would be medically necessary and the results of these tests will not change the management of the enrollee's 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenetic testing provided on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper and lower dentures.

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 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 complete upper and lower dentures.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that the enrollee was undergoing rehabilitation and making progress but then contracted COVID-19 in the facility which threw her rehabilitation off. You say that for over 2 weeks, she was sent to a different facility that did not offer rehabilitation services or the same level of care because of the COVID-19 diagnosis. The Plan denied your request. The Plan says medical necessity has not been established as skilled services are no longer needed on a daily basis to maintain function or prevent decline. Ongoing care can be provided at a lower 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 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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided the enrollee did not qualify for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 17, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that no services were rendered. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 $35 copayment for each in-person specialist visit. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows that you had a follow-up visit for right knee effusion and were given instruction on conservation measures for pain control such as physical therapy, medications, and bracing.
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 copayment for the specialist office visit provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI)
joint (64625).
You asked the Plan to pre-approve these services. You say that this procedure is the only thing that helped with
your pain. The Plan denied your request. The Plan says that the clinical value and effectiveness of
radiofrequency ablation to the SI joint in the setting of severe left sacroiliac joint arthritis has not been
demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. RFA of the lateral
sacral branches is considered experimental/investigational because of the wide variation in efficacy reported in
the literature. Our physician reviewer found that your condition does not meet Medicare criteria for these
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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint (64625).
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 care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met because the requested services are 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 that the enrollee continues to receive acute critical care services and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested care 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 that the enrollee does not require skilled nursing services with the specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron tab 8mg for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says this does not meet Part B criteria.

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 Ondansetron tab 8mg for
the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on January 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get prior authorization before receiving care. The requested provider in this case is not a network provider with the Plan. The requested services require prior authorization. The Plan did not pre-approve the services at issue. We found no exception that would require the
Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services you received on January 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone HCL 15 mg tablet.
You asked the Plan to pre-approve Oxycodone HCL. You say that this request is medically necessary. The Plan
denied your request. The Plan says this drug is not covered under your medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Oxycodone HCL 15 mg
tablet.
Benefits for Oxycodone HCL 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on
September 5, 2020.
You asked the Plan to pay for the evaluation and management services. You say that the enrollee was not
enrolled in hospice at the time of their discharge. The Plan denied your request. The Plan says the enrollee's
claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on
the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the
provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing
procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on
September 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trelegy Ellipta (J3535).
You asked the Plan to pre-approve Trelegy Ellipta (J3535). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug 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 Trelegy Ellipta (J3535).
Benefits for Trelegy Ellipta (J3535) 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 a spiral thigh lift.
You asked the Plan to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh (15832). You say that the excessive skin on your thighs causes physical pain and emotional distress. The Plan denied your request. The Plan says panniculectomy is approved but a spiral thigh lift does not meet Medicare rules for coverage.
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 excision, excessive skin and
subcutaneous tissue (includes lipectomy); thigh (15832). Our reviewer says that the requested service is not
considered medically reasonable and necessary in this case. Our physician reviewer found the totality of the
records, including photographs, indicates that the requested procedure is being performed for body contouring
purposes. The requested procedure is cosmetic in nature. The elements of the coverage criteria are not satisfied.
The requested service cannot be 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 excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
(15832) have not been met. Therefore, we decided that the Plan does not have to pre-approve a spiral thigh lift.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services 5 visits a week
You asked the Plan to pre-approve skilled nursing services. You say that the enrollee has no willing or acceptable caregivers to assist her with her medical needs in her home. The Plan denied your request. The Plan says skilled nursing services was reduced to 2 visits a week as there is no documentation that 5 days a week of skilled nursing is medically necessary.
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 skilled nursing services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found based on the medical records provided there is no documentation that skilled nursing services five days per week (as opposed to two days per week) are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. Records do not indicate such medical instability that five days per week skilled nursing services are necessary. Medication administration is not a skilled service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing services 5 visits a week
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for Fundus Photography provided on
December 30, 2020.
You asked the Plan to reimburse you for the Fundus photography. The Plan denied your request. The Plan says you do not have a diagnosis supporting the need for this test.
The Plan must follow Medicare rules. Medicare rules say that Fundus Photography is not covered for routine screening. We looked at the file and Medicare rules. The file shows that the Plan confirmed with the physician that you do not have a supporting diagnosis for this test. Therefore, we decided that the Plan does not have to reimburse you for Fundus Photography provided on December 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced pneumatic compression device (E0652, E0667).
You asked the Plan to pre-approve the advanced pneumatic compression device. You say that the advanced compression device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a four-week trial of conservative therapy demonstrating failed response to treatment with an basic device (E0650 or E0651) is required. 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 advanced pneumatic compression device. Our reviewer says that the requested device is not medically necessary. Our physician reviewer found the patient had tried and failed exercises, simple compression garments, and a regular compression device (in-office) prior to the advanced pneumatic compression device being considered. However, the records did not describe evidence of truncal edema or a longer in-home trial of at least 4 weeks of the regular pump. 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 advanced pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced pneumatic compression device (E0652, E0667).