Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee. You asked the Plan to pre-approve IRF care. You say that the enrollee is declining. The Plan denied your request. The Plan says the services are not medically necessary. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has recent functional decline and is showing some mild fluid overload due to congestive heart failure. He needs minimal assist with mobility and transfers. He has no complex issues that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from further therapy but does not require an intensive therapy program 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910 x 3) provided from February 5, 2019 to September 25, 2019.
You asked the Plan to reimburse you for the dental services. You say that you received periodontal maintenance, which is a dental cleaning code for those who have a history of periodontal disease. You say that this service is preventive in nature thus should be covered. You say that your dentist advised that people with periodontal disease have their cleanings under dental code D4910, not prophylaxis D1110. The Plan denied your request. The Plan says periodontal maintenance is not a preventive dental service. The Plan also says that periodontal maintenance is not listed as a covered service.
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, periodontal maintenance is not among those covered under this benefit. The Evidence of Coverage clearly states that prophylaxis is the only type of cleaning that is covered by the Plan. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910 x 3) provided from February 5, 2019 to September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are contracted providers available.
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 a referral an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sildenafil.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 Sildenafil.
Benefits for these services 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says care can be provided in another setting such as a skilled nursing facility, outpatient setting or home health care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound/skin and O2 care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly minimum assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy can allow for measurable gains to be achieved within a predicted period. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture.
You asked the Plan to pre-approve these services. You say that you are unable to eat without the dentures. The Plan denied your request. The Plan says you have exhausted the benefit limit.
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. The Plan covers a complete lower denture once every five plan years. The item at issue is a complete lower denture. The file shows that you previously were approved for a complete lower denture on August 1, 2019. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete lower denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says your current medical conditions are stable and without any complications.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment in an intensive rehabilitation therapy program. There is concern that you would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 Eliquis for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that acute rehab would bring the enrollee's speech back to a place where she can function independently.The Plan denied your request. The Plan says that based on her current functional level it appears that she would be able to get the needed rehab at a skilled nursing facility.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The patient is generally medically stable, with recent mild stroke with right hemiparesis and aphasia, after left carotid endarterectomy. There is no evidence of complex medical issues that requiremonitoring by an inpatient physical medicine and rehab physician three times per week or need for acute rehab nursing care. While the enrollee may benefit from continuing physical therapy, speech and occupation therapy, there is no evidence of need for anintensive therapy program at her current functional level as noted above with therapy three hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met.Therefore, we decided that the Plandoes not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration and a bone graft.
You asked the Plan to pre-approve these services. You say that you are scheduled for surgery and are in pain. The Plan denied your request. The Plan says the knee surgery is approved but the bone aspiration and bone graft are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have persistent left knee pain that limits functional mobility. The plan has approved a knee arthroscopy surgery. The use of bone marrow aspiration and bone graft is not considered the standard of care for this procedure. The services are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration and a bone graft.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's rehabilitation needs are not complex.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. In this case, a less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient behavioral health facility for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says treatment needs can be met at less restrictive outpatient level of care.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided, the enrollee does not meet the criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others but was without agitation or aggression without perceptual disturbance including auditory or visual hallucinations. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient behavioral health facility for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chair/stair lift for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is denied by Medicare as a convenience item. Therefore, we decided that the Plan does not have to pre-approve a chair/stair lift for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percutaneous Image-Guided Lumbar Decompression (PILD).
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says this is only covered when provided as part of a clinical study.
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when provided in a clinical study. We looked at the file and Medicare rules. The documentation provided does not show that the requested PILD services will be provided as part of a clinical study. 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 Percutaneous Image-Guided Lumbar Decompression (PILD).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the requested services have been found to be 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you feel that you should be allowed a SNF stay since you want to be able to get therapy on a daily basis. The Plan denied your request. The Plan says your condition does not require daily skilled services to maintain your condition or prevent deterioration.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on 3/2/2020 due to alcohol abuse, elevated liver enzymes, and weakness. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. He was treated for alcohol withdrawal with Librium. Regarding rehabilitation services, the beneficiary received PT in the acute hospital. The beneficiary was at a stand by assist level with functional mobility including gait to 140 feet with a rolling walker. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, therapy is not required on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental extraction to be provided by an out of network oral surgeon.
You asked the Plan to pre-approve the dental services. You say that your wisdom tooth is infected because the filling fell out and the infection is moving to the root. The Plan denied your request. The Plan says the records provided indicate that you have a tooth infection requiring the tooth to be removed. This is not a service that would be medically necessary under the medical insurance 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. The health plan Evidence of Coverage on pages 61-62 specifically says a referral is required to visit an oral surgeon for Medicare covered services and those services require a prior authorization and that simple and surgical extractions are covered when provided by a contracted dental provider. The requested provider is not a contracted dental provider. 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 the dental extraction to be provided by an out of network oral surgeon.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a transforaminal epidural steroid injection (ESI) for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an ESI is covered when specific criteria are met. 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 medically necessary. Our physician reviewer found the enrollee has bilateral radiculopathy and documented disc displacement at the S1 nerve root. She had a prior ESI with 50 percent pain relief for several weeks. She meets the criteria for coverage of a repeat ESI and also has indicates for monitored anesthesia care due to a history of morbid obesity, anxiety, and post-traumatic stress disorder. The requested services are reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve a transforaminal epidural steroid injection (ESI) for the enrollee.