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.

You asked the Plan to pre-approve SNF services. You say that you require additional therapy and skilled
nursing. The Plan denied your request. The Plan says that you no longer require daily skilled services and the
continuation of SNF 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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for continued 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 continued skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.

You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you need this transportation to attend medical appointments. The Plan denied your request. The Plan says that your request exceeds the mileage limits.

Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve strabismus surgery.

You asked the Plan to pre-approve strabismus surgery. You say that the requested strabismus surgery to treat the enrollee's diagnosis of exotropia with horizontal diplopia is medically necessary as it affects her quality of life. The Plan denied your request. The Plan says the requested surgery may be cosmetic and is not covered.

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 strabismus surgery. Our reviewer says that the requested strabismus surgery is not medically necessary. Our physician reviewer found the enrollee is primarily concerned with the appearance of the eye. The documentation provided indicates the enrollee had vision impairment due to macular degeneration. The provider indicated that it was early to operate. The record indicates the enrollee wanted the surgery at an earlier convenient time due to an upcoming wedding. The elements of the coverage rule 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 strabismus surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve strabismus surgery.
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 SNF care. You say that the services requested are medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.

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 the beneficiary is a 74-year-old male with gangrenous tissue on both feet currently in an inpatient rehabilitation facility. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and 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 SNF care 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 alveoloplasty in conjunction with extractions (D7310).

You asked the Plan to pre-approve dental code D7310. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested dental services are not covered by Medicare or the Plan's supplemental dental 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, dental code D7310 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fixed partial dentures.

You asked the Plan to pre-approve fixed partial dentures. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested services.

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 fixed partial dentures when the services are medically necessary and reasonable.

We looked at the file and Medicare rules. The documentation does not support that you have a physical, neurologic, or special needs condition that precludes use of a removable denture. Based on this information, we decided that the Plan's rules for coverage of fixed partial dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve fixed partial dentures.
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 SNF care. You say that you need SNF care.The Plan denied your request. The Plan says rules for SNF care have not been met.

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 you are an 84-year-old female with diabetes, atrial fibrillation, pulmonary fibrosis who received therapy services in the acute care hospital. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and 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 SNF care 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Victoza.
You asked the Plan to pre-approve Victoza. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Victoza.
Benefits for Victoza 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: 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 the skills of a therapist 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 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn injections.

You asked the Plan to pre-approve Gelsyn injections. You say that Gelsyn injections are medically necessary. The Plan denied your request. The Plan says Gelsyn injections 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 Gelsyn injections. Our reviewer says that Gelsyn injections are not medically necessary. Our physician reviewer found detailed documentation is not evident regarding at least 6 months' time having passed since the previous injection on 1/21/21. Furthermore, documentation indicates there was no significant benefit received with that injection. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. LCD criteria for the requested Gelsyn injections have not been met. Therefore, the request for Gelsyn injection, right knee is not medically reasonable or 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 Gelsyn injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gynecological care to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the OON gynecological care. You say that the enrollee wishes to see this OON provider because she will need surgery and is staying with family in Houston. She has no care available in Beaumont so a surgeon in Houston is required. The Plan denied your request. The Plan says it was found that the plan's network has several providers in their area who can provide the care the enrollee needs. As there is no network deficiency, OON care is not required.

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 gynecological care to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair, or power mobility device (PMD).

You asked the Plan to pre-approve the PMD. You say that the PMD should be authorized. The Plan denied
your request. The Plan says there is insufficient documentation to reflect medical necessity.

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.

The file shows that the documentation does not reflect that a physical exam was done to determine the mobility
deficit or level of assistance required to assist with activities of daily living. This means that Medicare rules for
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a
power wheelchair, or power mobility device (PMD).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 28 additional visits to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.

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 28 additional visits to be provided by an out of network (OON) provider.

We note that the Plan has approved two of the requested 30 total visits with this provider to be able to transition to an in network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Medtronic continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that the patient is unable to use the Freestyle Libre as it is incompatible with the insulin pump being used. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. This type of monitor is not considered therapeutic. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Medtronic continuous glucose monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flex/Walk foot component coded as L5981 and a residual limb vacuum pump coded as L5781.
You asked the Plan to pre-approve the requested prosthetic leg components. You say that these items are medically necessary. The Plan denied your request. The Plan says there is no evidence to support the need for these components.
The Plan follows Medicare rules. Medicare rules say that certain components of a prosthetic leg are considered reasonable and necessary based on the enrollee's functional level 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 the requested prosthetic leg components. Our reviewer says that the documentation does not support that the coverage criteria for the requested components are met. Our physician reviewer found the enrollee is a 74-year-old woman who underwent a transtibial amputation of the left lower extremity in 1995. It is documented that the enrollee is in need of a new prosthesis. It is noted that the foot of the old prosthesis is worn out, and the socket fits poorly. The case file does not contain clinical records for review.
The limited clinical documentation does not support that the enrollee is a level 3 functional ambulator. This means that the criteria for coverage of the Flex-Walk foot are not met. The documentation also does not support the medical necessity of a residual limb vacuum pump for the enrollee 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 the requested prosthetic leg components have not been met. Therefore, we decided that the Plan does not have to pre-approve a Flex/Walk foot component coded as L5981 and a residual limb vacuum pump coded as L5781.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Monovisc.
You asked the Plan to pre-approve a tier exception for Monovisc. You say that the exception is needed. The Plan denied your request. The Plan says Part B medications do not qualify for tier exceptions.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Monovisc.
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 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 has a past medical history of hypothyroidism, hyperlipidemia, anxiety, and depression and presented to the acute hospital on April 2, 2021, with COVID-19 pneumonia. The short-term acute care hospital can provide for all of the enrollee's present inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. The Plan has stated that continued care in the short-term acute care hospital will be covered. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility, or a skilled nursing 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of 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 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at an alternate 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.