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

We decided that the Plan does not have to pre-approve inpatient mental health care from November 24, 2020, 
forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is 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 based upon review the records provided it was not expected this enrollee would 
improve in a reasonable period of time for the dates in question as they did not have suicidal or homicidal 
ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment 
while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question as the enrollee did not have dangerousness to self or others but was compliant with their treatment. 
The health plan's denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear 
to require inpatient mental health treatment beyond the date in question as the enrollee was not a danger to 
themselves or others and did not have any auditory or visual hallucinations while being cooperative with 
treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear 
that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis 
beyond the date in question. Our physician reviewer was unable to find an individualized treatment plan 
however the entire chart is not present. It did appear that the records were supervised and evaluated by a 
physician. Based upon review the records provided for the admission of this enrollee does not meet the criteria 
for continued acute inpatient mental health treatment for the dates in question of November 24, 2020 forward 
as this enrollee was not shown to be a danger to themselves or others. The enrollee was not showing any 
auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats 
the 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 inpatient mental health care from November 24, 2020, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe clinical crown lengthening.You asked the Plan to pre-approvethe clinical crown lengthening. You say that this has to be done in order to place the crown on the tooth. You say that without a crown there is the possibility of infection and needing a root canal.The Plan denied your request. The Plan says the service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not have to pre-approvethe clinical crown lengthening.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found at the time of admission, you required skilled 
rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. 
You did not require skilled therapy to establish a safe and effective maintenance program. As a practical 
matter, you did not require any skilled services on an inpatient basis, at a SNF level of care during the period of 
care under review. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's 
condition under Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
Benefits for the Prolia 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation 
 
You asked the Plan to pre-approve additional routine transportation. You say that additional transportation is 
necessary for appointments. The Plan denied your request. The Plan says once this benefit is exhausted it 
cannot be extended. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
Medicare does not provide coverage for routine transportation. The Plan covers 10 one-way trips per year. 
Based on the records provided, you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Go-Go Elite Travel Plus Scooter. 
 
You asked the Plan to pre-approve a Go-Go Elite Travel Plus Scooter. You say that you need this scooter 
because you cannot maneuver the one you got from the plan. The Plan denied your request. The Plan says that 
Medicare does not cover back up scooters. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a heavy-duty power scooter. A heavy-duty power scooter serves the same purpose 
as a Go-Go Elite Travel Plus Scooter. Therefore, we decided that the Plan does not have to pre-approve a Go-
Go Elite Travel Plus Scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings are required. The 
Plan denied your request. The Plan says gradient compression stockings are not covered because they are 
wound care items which are non-covered under the surgical dressing benefit because they do not meet the 
statutory definition of a dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve these services. You say that you need the ramp to evacuate your home in 
emergencies. 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 rules state that for equipment to be covered, it must be appropriate and needed for use 
inside the home. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The item is also 
being requested for use outside of the home and Medicare does not cover equipment for this purpose. 
Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve 24 additional routine transports. 
 
You asked the Plan to approve these services. You say that you need additional trips. The Plan denied your 
request. The Plan says you have exhausted the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to approve 24 additional routine transports.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee can be treated in a lower level of care. 
 
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 does not require services in the LTACH that are not already available at 
the current facility. There are no services at the LTACH that are not already available and covered at the 
current facility. This request for LTACH services will be considered not 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 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 Botox injection (CPT Code J0585) and esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance (43236)

.You asked the Plan to pre-approvethe services. You say that the enrollee suffers from refractory gastroparesis and has not responded to a fastroparesis diet, metoclopramide, and domperidone. You state upper endoscopy with Botox injections of the pylorus has shown benefit inpatients with gastroparesis.

The Plan denied your request. The Plan says the LCD and LCA says that only conditions listed are medically necessary; gastroparesis is not listed as one of these conditions.

 The Plan reviewed the drug compendia, medical literature, and guidelines and did not find conclusive evidence that Botox is effective for gastroparesis.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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the Botox injection(s) at issue in this case are medically reasonable and necessary based on the Medicare rules. None of the Medicare-approved compendia support the use of Botox for gastroparesis as either a Food and Drug Administration-approved indication or an off-label indication.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 Botox injection (CPT Code J0585) and esophaggastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance (43236).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the orbit, face, 
and/or neck (70543) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve an MRI of the orbit, face, and/or neck. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
this care. Therefore, coverage criteria has not been met. 
 
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 magnetic resonance imaging (MRI) of the orbit, face, and/or neck (70543) to be provided by an out of 
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Krystexxa infusion. 
 
You asked the Plan to pre-approve Krystexxa infusion (J2507). You say that you want the enrollee treated with 
this drug. The Plan denied your request. The Plan says the request does not meet medical necessity criteria. 
 
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 Krystexxa infusion (J2507). Our 
reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found based on 
the medical records provided there is no documentation that the Krystexxa is safe and effective for the enrollee. 
The enrollee has achieved a normal uric acid level on Uloric. The enrollee does not meet criteria for utilization 
of Krystexxa. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Krystexxa infusion (J2507) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Krystexxa infusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve So clean brand breathing machine cleaner. 
 
You asked the Plan to pre-approve So clean brand breathing machine cleaner. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
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 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve So clean brand breathing machine cleaner.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight manual wheelchair (K0003). 
 
You asked the Plan to pre-approve a lightweight manual wheelchair. You say that the enrollee cannot use her 
power wheelchair. The Plan denied your request. The Plan says the enrollee's needs can be met with her current 
power wheelchair. The Plan has also indicated they will schedule driver training to help the enrollee get more 
comfortable with the power wheelchair. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a power wheelchair. A power wheelchair serves the same purpose as a 
lightweight manual wheelchair. Therefore, we decided that the Plan does not have to pre-approve a lightweight 
manual wheelchair (K0003).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional occupational therapy (OT) sessions 
(97168). 
 
You asked the Plan to pre-approve additional OT sessions. You say that you are requesting an appeal for 7 
visits. The Plan denied your request. The Plan says the additional OT visits are not reasonable and 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 additional OT sessions. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  
 
 
 
 
Our physician reviewer found based on the medical records provided there is no documentation that the 
enrollee meets the requirements listed in the Local Coverage Determination for Medicare coverage for the 
additional occupational therapy treatments. Based on the available records the enrollee appears to have 
plateaued with therapy. Further therapy at this point does not appear to be likely to achieve any significant 
improvement in the enrollee's functional status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional OT sessions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional occupational therapy (OT) sessions (97168).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VENCLEXTA tablets. 
 
You asked the Plan to pre-approve the VENCLEXTA tablets. You say that you have had a relapse in your 
myelodysplastic syndrome and need this treatment. The Plan denied your request. The Plan says this oral drug 
is not covered by Medicare Part B. Part D coverage must be requested. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs.  
 
This oral anti-cancer drug does not have an injectable form. As such, it is not among those covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve VENCLEXTA tablets.  
 
Benefits for the VENCLEXTA tablets may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 16, 2019 by an 
out of network provider. 
 
You asked the Plan to pay for the medical services. You say that the physician treated the enrollee in good 
faith. The Plan denied your request. The Plan says you did not request 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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on December 16, 
2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of intra-socket biological dressing to aid in 
hemostasis or clot stabilization, per site (D7922 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that you need extractions. You say that your 
dentist requested these services so that he could do the extractions. You say that you have a clotting issue and 
would bleed out without these services being approved. The Plan denied your request. The Plan says placement 
of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site, 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, 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 
placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922 x 4).