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

We decided that the Plan does not have to pre-approve Orbactiv

You asked the Plan to pre-approve Orbactiv. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says Orbactiv is not being prescribed for a medically-accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Orbactiv. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found that the patient is a 67-year-old female with a history of left breast cancer status post left mastectomy and axillary node dissection in 2009 who recently underwent removal of breast implant due to an infection. Antibiotics were administered and after starting antibiotics, a culture around the implant grew Staphylococcus epidermidis suggestive of colonization related to post-antibiotic use. The culture revealed susceptibility to multiple first line antibiotics but not Orbactiv. A request for IV Orbactiv was made for her skin and soft tissue infection. Orbactiv is not specifically FDA-approved and indicated for Staphylococcus epidermidis infection as detailed in the prescribing information. This antibiotic is also not supported by the major drug compendia.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orbactiv have not been met. Therefore, we decided that the Plan does not have to pre-approve Orbactiv.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the enrollee has COPD and needs the requested ventilator for respiratory support. You say that the requested life saving device will allow the enrollee to maintain activities of daily living and decrease the frequency of exacerbations and hospitalizations. You say that the requested device will help to identify any progression in the enrollee's condition. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 portable ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically necessary. This enrollee has COPD, but there is no documentation of CO2 retention on an ABG,
done while the patient is stable. Medicare does not cover a home ventilator when used as BiPAP. 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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and
accessories (E0667).
You asked the Plan to pre-approve a pneumatic compression device and accessories.. You say that the enrollee
failed conservative measures for more than four weeks. The Plan denied your request. The Plan says the
requirements for coverage have been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device
(E0652) and accessories (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for multivitamin injections (J3490) provided December 16, 2020.

You asked the Plan to pay for the multivitamin injections. You say that the injections were medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the multivitamin injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Vitamin injections into the nerve and musculoskeletal structures are not a Medicare covered service.

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 multivitamin injections have not been met. Therefore, we decided that the Plan does not have to pay for multivitamin injections (J3490) provided December 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to waive the deductible applied to services provided on February 15, 2021.
You asked the Plan to waive the cost share applied to the deductible. You say that you did not have to pay a deductible for services from this physician until you joined the Plan. You say that no one told you about the deductible. The Plan denied your request. The Plan says this cost share was applied based on the Plan contract agreement and the physicians out of network status.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a deductible for out of network services. This cost sharing is a contractual obligation. Therefore, we decided that the Plan does not have to waive the $93.06 deductible applied to physician services provided on February 15, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient mental health care provided on October 10, 2020, to October 26, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the inpatient mental health care. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 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 had network providers available who could have provided 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 inpatient mental health care provided on October 10, 2020, to October 26, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 18, 19, 30, and 31.

You asked the Plan to pre-approve the crowns. You say that you need the crowns in order to chew your food properly. The Plan denied your request. The Plan says the crowns are not medically necessary.

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 the crowns when the services are medically necessary and reasonable. 

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 crowns. Our reviewer says that given the lack of notable structural loss and the furcation involvement of tooth #19, and the moderate to severe loss of bone on #18, 30, and 31 there is no necessity for the requested procedures at this time. Our physician reviewer found the provided x-rays are of poor diagnostic quality and assessment is difficult. It is clearly seen that tooth #19 has a furcation involvement which decreases the long term stability and prognosis of the tooth.

Our reviewer found that the other teeth also suffer from periodontal disease and show about 40% bone loss. The bone loss into the furcation areas of #18, 30, and 31 is not clear from the supplied x-rays or records. Our physician reviewer also found that it is also not clear as to the need for crowns on these teeth, as it cannot be seen if there is any extensive loss of structure from trauma or decay on any of the teeth in question. Crowns may be indicated where there is extensive loss of structure and the tooth requires the strength of a full coverage restoration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 18, 19, 30, and 31.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from October 31, 2020 to November 1, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were unauthorized post-stabilization care.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the enrollee was stable for transfer to a network facility. Our physician reviewer found the enrollee presented to the emergency department (ED) with nausea and vomiting, headache, lightheadedness, lethargy, shortness of breath, and recent positive COVID-19 testing. Vitals were stable on examination in the ED without hypoxia. She was given antibiotics for suspected UTI and Zofran with improved symptoms. There was no time where the patient was noted to be unstable. The records support she was hemodynamically stable for transfer to a network 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from October 31, 2020 to November 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee from August 18, 2020, to September 29, 2020.

You asked the Plan to pay for out of network services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 physician services provided to the enrollee from August 18, 2020, to September 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care.

You asked the Plan to pre-approve inpatient mental health care. You say that this request is medically necessary. The Plan denied your request. The Plan says the coverage criteria for inpatient mental health care have not been met.

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 reviewer says that the requested inpatient mental health care is not medically necessary. Our physician reviewer found that the enrollee is a 48-year-old female who was admitted to the acute inpatient psychiatric hospital on July 7, 2021, with Major Depressive Disorder, Recurrent, Severe without Psychotic Features and Cocaine Use Disorder, Severe. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as she did not have active dangerousness to self or others and was not showing any auditory/visual hallucinations or any aggressive behaviors. 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 as she did not have dangerousness to self or others. Based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to herself or others, no 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 inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care.
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 your life was put into danger at the last facility. You say that you need to be in a secure and safe environment. The Plan denied your request. The Plan says the requirements for approval of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.

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 a diabetic foot ulcer and had a below the knee amputation. The enrollee's medical conditions 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF).
You asked the Plan to pre-approve the continuation of SNF care. You say that the enrollee continues to require SNF care. The Plan denied your request. The Plan says the enrollee no longer qualifies for SNF care.
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 the continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee does
not have documented skilled nursing needs. Also, the enrollee does not have documented skilled therapy needs.
The enrollee appears to have reached a new level of function. Daily skilled services are not shown to be
required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The
enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 the continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF).
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 IRF admission is medically necessary to help the enrollee better manage care and independence once returning home. The Plan denied your request. The Plan says the enrollee can receive care at lower level. The criteria for IRF admission has not been met.

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 that 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. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF stay.

You asked the Plan to pre-approve the SNF stay. The Plan denied your request. The Plan says the services the enrollee requires do not require daily inpatient skilled nursing and/or therapy services.

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 the SNF stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair.
You asked the Plan to pre-approve a recliner chair. You say that you have multiple medical issues and have extreme difficulty getting up out of a chair. 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 a recliner chair.