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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond May 5, 2020.
You asked the Plan to pre-approve these services. You say that the enrollee has not been able to progress with recovery. The Plan denied your request. The Plan says the continued services are 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF on April 14, 2020 after a fall with rib fractures. As of May 5, 2020, his transfers hadn't improved since admission. He was able to walk 75 feet with a two-wheeled walker and moderate assistance, and his wheelchair mobility was 100 feet with assistance. He has no skilled nursing or skilled therapy needs. He does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond May 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Buprenorphine patches.
You asked the Plan to pre-approve Buprenorphine. You say that the enrollee has chronic back pain. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Buprenorphine patches.
Benefits for Buprenorphine 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 pay for the knee orthoses and sleeves provided to the enrollee on December 23, 2019.
You asked the Plan to pay for the orthoses and sleeves. The Plan denied your request. The Plan says that the billed supply code cannot be verified.
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 orthoses and sleeves. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity. Our physician reviewer found that the enrollee's condition does not meet criteria for these items. 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 orthoses and sleeves have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and sleeves provided to the enrollee on December 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care provided from February 21, 2020 to discharge, for the enrollee.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay was 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 inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found the health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. This patient was treated under an individualized treatment plan found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to herself or others, no auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care provided from February 21, 2020 to discharge, for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
You asked the Plan to pre-approve the MRI. You say that The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found the enrollee has a past medical history of fibromyalgia, neck pain, back pain, migraines, IBS and arthritis. She complains of widespread pain. There are no focal complaints related to the neck or upper extremities that suggest neurological involvement. The physical examination documents 15 of 18 positive point on a widespread pain assessment. There is no documentation of any focal neurologic deficits. In this case, there are neither focal symptoms nor are there focal neurologic findings for which an MRI is needed for diagnostic purposes. There was no rationale given in the medical record for ordering an MRI of the cervical plan and no documentation that management would be altered by the results of an MRI. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the doctor said that it was necessary to prevent DVT. The Plan denied your request. The Plan says PCD are not covered for the prevention of venous thromboembolism.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair, weight capacity 301 to 450 pounds (K0825).
You asked the Plan to pre-approve a power wheelchair. You say that the enrollee has been using a Jazzy Elite HD model chair for the last 8 years and he is comfortable and confident with its use. He is under the weight capacity and is expecting to lose more weight. The Plan denied your request. The Plan says the criterion is not met for the power wheelchair because the enrollee's weight is greater than or equal to 95% of the weight capacity of the requested chair.
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 a power wheelchair. Our reviewer says that this enrollee does not meet the medical necessity criteria for a power wheelchair. Our physician reviewer found the documentation does not indicate the enrollee can safely operate the requested PMD as the enrollee weighs 438 lbs. A heavy duty power wheelchair is covered for a beneficiary weighing 285 - 450 pounds; a very heavy duty power wheelchair is covered for a beneficiary weighing 428 - 600 pounds. The enrollee is appropriate for a very heavy duty power operated wheelchair rather than a heavy duty power wheelchair therefore the criteria for a Group 2 HD power wheelchair 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 a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair, weight capacity 301 to 450 pounds (K0825).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro robotic assisted rehabilitation device (L8702).
You asked the Plan to pre-approve the MyoPro robotic assisted rehabilitation device. You say that given the enrollee's history and the abundance of evidence in his favor, there can be no doubt as to the reasonableness and medical necessity of this request. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness to the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MyoPro robotic assisted rehabilitation device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro robotic assisted rehabilitation device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need the orthotics because of foot pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair for the enrollee.
You asked the Plan to pre-approve a Group 2 power wheelchair. The Plan denied your request. The Plan says that a less costly power operated vehicle must be ruled out in order to qualify for a power wheelchair.
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 Group 2 power wheelchair. Our reviewer says that a Group 2 power wheelchair is not considered medically reasonable and necessary in this case. The medical records indicate the enrollee has suffered falls, and has gait instability. The enrollee has difficulty manipulating a wheelchair or walker. The enrollee is not noted to have inability to utilize a lesser device (lightweight manual wheelchair). Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Group 2 power wheelchair. 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 Group 2 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral hip and low back pain. She has been treated with Meloxicam and Tylenol. There is no documentation of six weeks of conservative management and a clinical re-evaluation; therefore, the MRI is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esomeprazole Magnesium.
You asked the Plan to pre-approve the requested drug. You say that the enrollee has been stable on treatment. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Esomeprazole Magnesium.
Benefits for the requested drug 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: 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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 enrollee was admitted to acute care on 4/27/20 with left foot wet gangrene. He underwent a left foot transmetatarsal amputation on 5/1/20 for possible osteomyelitis. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include surveillance laboratory studies, intravenous antibiotics, wound care, fluid balance, and therapy services. 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. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services.
You asked the Plan to pre-approve the requested services. You say that the enrollee needs extractions for cancer-related deterioration due to radiation. The Plan denied your request. The Plan says dental extractions are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower partial denture reline (D5761).
You asked the Plan to pre-approve lower partial denture reline. You say that you have a lower denture that is rubbing on the gum of the stationary holding tooth which becomes reddened and sore as you chew. The Plan denied your request. The Plan says this request exceeds the frequency limitations.
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. This service is allowed once every 2 years. The records show that the enrollee had a lower partial denture reline done on July 19, 2018. 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 lower partial denture reline (D5761).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 1, 2019.
You asked the Plan to pay for the physician's services. You say that this provider's appointment was made based on the recommendation of your oncologist and that is why you believe you should not have to pay for this service. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided on August 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary due to significant concern regarding the enrollee's disposition and safe discharge planning. The Plan denied your request. The Plan says this 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 enrollee is currently undergoing treatment at an ACH for recurrent cellulitis in the setting of morbid obesity. The enrollee is receiving wound care and antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.