Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair and accessories.

You asked the Plan to pre-approve a Group 2 multiple power option power wheelchair (K0843) with power seating tilt (E1002). You say that you want independent mobility to move in an outside the home. The Plan denied your request. The Plan says the Physical Therapist documents that you can functionally weight shift and therefore do not qualify for the tilt function on this wheelchair.

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 Group 2 power wheelchair (K0843) with tilt (E1002). Our reviewer says that a review online of the requested wheelchair indicates that this is actually a Group 3 wheelchair. Our physician reviewer found the enrollee has a mobility deficit which impairs MRADLs in the home and is unable to be helped by a walker, cane, or manual wheelchair, however the patient does not have a qualifying Group 3 diagnosis. This is also confirmed by the May 10, 2021 Assistive Technology Professionals (ATP) document which states patient does not have a qualifying Group 3 diagnosis. 

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 (K0843) with tilt (E1002) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair and accessories.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (73502) provided December 6, 2020.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT code 73502 is not supported in the medical record. Specifically, the CPT code was billed with the LT (left) anatomical modifier. The Diagnosis code billed is for a right-side femur fracture. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (73502) provided December 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment - includes placement 
(D6057) and abutment supported porcelain/ceramic crown (D6058) provided March 24, 2021. 
 
You asked the Plan to pay for the custom abutment and abutment supported crown. You say that the services 
were medically necessary. The Plan denied your request. The Plan says these services are not covered under 
your benefits. 
 
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 pay for the custom fabricated abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown 
(D6058) provided March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140).
You asked the Plan to pre-approve a tooth extraction. You say that the tooth extraction is medically necessary, and you would like it covered. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 an extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the enrollee has been stable on this medication for 
years. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 
Medicare Part B. 
 
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.Benefits for Eliquis 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Nulojix Injection (J0485).
You asked the Plan to pre-approve Nulojix Injection, belatacept, 1 mg (J0485) to be administered at outpatient facility/hospital. You say that you want to be treated with this drug. The Plan denied your request. The Plan says that you do not meet the clinical criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Nulojix Injection, belatacept, 1 mg (J0485) to be administered at outpatient facility/hospital. Our reviewer says that the drug is medically reasonable and necessary. Our physician reviewer found the reason for denial is not met. The patient has negative Epstein-Bar Virus (EBV) Immunoglobulin M (IgM) (which is positive during acute infection) but has positive Immunoglobulin G (IgG), therefore is not seronegative for EBV and the reason for the denial is not justified. The medication is reasonable in this patient with rapidly declining function of new allograft. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nulojix Injection, belatacept, 1 mg (J0485) to be administered at outpatient facility/hospital have been met. Therefore, we decided that the Plan has to pre-approve Nulojix Injection (J0485).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a myoelectric elbow-wrist-hand-finger orthosis for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that this device is helpful for treatment of the health problem.
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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the case file does not contain clinical records for this enrollee. The documentation does not support that the MyoPro Motion G Orthotic device was medically reasonable and necessary 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a myoelectric elbow-wrist-hand-finger orthosis for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs admission to acute inpatient rehabilitation. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for left total hip replacement and was discharged home with home health on August 27, 2021. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for special supplemental benefits.
You asked the Plan to pre-approve coverage for special supplemental benefits. You say that you are requesting an appeal for the denied supplemental benefits. The Plan denied your request. The Plan says you do not meet the criteria to receive the Special Supplemental Benefits.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the special supplemental benefits have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve coverage for special supplemental benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network urologist.
You asked the Plan to pre-approve these services. You say that the procedure you need is not offered in-network. The Plan denied your request. The Plan says the services are available from network providers.
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. The Plan confirmed that the network providers are available to evaluate your condition and provide the Greenlight Laser treatment if necessary. 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 to an out-of-network urologist
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from August 26, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that you are seeing hallucinations of sad faces on the nurses and staff instead of smiling faces. You state you still need inpatient care due to the fact that you are not able and in the mental state to go home and look after yourself or others. 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 you did not require inpatient mental health treatment beyond the dates in question as noted above as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Our physician reviewer was unable to find an individualized treatment plan however the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of August 26, 2021, forward and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 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 continuation of inpatient mental health care from August 26, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on November 19, 2020. 
 
You asked the Plan to pay for the dental services. You say that you went out of the way to enable the patient to 
function and chew food. You say that you are only requesting 50% of the charges to cover your costs. The Plan 
denied your request. The Plan says the maximum benefit allowed by the member's dental plan has been paid. We decided that the Plan does not have to pay for the dental services provided on November 19, 2020. 
 
You asked the Plan to pay for the dental services. You say that you went out of the way to enable the patient to 
function and chew food. You say that you are only requesting 50% of the charges to cover your costs. The Plan 
denied your request. The Plan says the maximum benefit allowed by the member's dental plan has been paid.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 Plan also has a maximum benefit 
of $500 every year for preventive and comprehensive dental services. The Plan paid $500 toward the dental 
services provided on March 4, 2020 and October 15, 2020, which exhausted their benefits. Therefore, we 
decided that the Plan does not have to pay for the dental services provided on November 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy with an out-of-network provider.
You asked the Plan to pre-approve out-of-network physical therapy. You say that the patient has been here before and is comfortable with your facility. You say that she would like to continue to come here and you attached the referral from the primary care physician. The Plan denied your request. The Plan says services must be rendered by network providers and in-network providers are 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 physical therapy with an out-of-network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says you have not tried Synvisc, Durolane, and Gelsyn-3.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We looked at the file, and Medicare rules. The Plan requires a trial of Synvisc, Durolane, and Gelsyn-3 before they will approve the requested drug. In this case, there are insufficient medical records to show that you have tried and failed the required drugs. The file shows that the Plan requested additional records on multiple occasions, with no success. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the requested services. You say that in-network personnel are not capable of saving the enrollee's life. The Plan denied your request. The Plan says care can be treated 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested services. Therefore, we decided that the Plan does not have to pre-approve an office visit 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 provide a therapeutic continuous glucose monitor. 
 
You asked the Plan to provide a therapeutic continuous glucose monitor (K0553). You say that the enrollee has 
poorly controlled diabetes and needs a CGM. The Plan denied your request. The Plan says based on the notes 
the enrollee does not meet the rules for approval of this device. 
 
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 and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections nor requires 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 a therapeutic 
continuous glucose monitor (K0553) have not been met. Therefore, we decided that the Plan does not have to 
provide a therapeutic continuous glucose monitor.
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 you disagree with the denial. 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for osteomyelitis and discitis. He was discharged to skilled nursing from June 11, 2021 to August 2, 2021 and remains in the facility as a long-term care resident. He is medically stable with no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.