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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

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 based on Medicare guidelines and the information we have about the enrollee's condition; the enrollee does not meet the requirements for IRF admission.

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 pay for skilled nursing facility services provided December 1, 2020 to December 30, 2020.

You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically necessary. The Plan denied your request. The Plan says 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 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 pay for the skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. The enrollee was ambulating 100 feet and tending to ADLs with minimal supervision. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 

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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided December 1, 2020 to December 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that the enrollee has been using these supplies for a long time and needs them to protect skin, clothing, and bedding. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional catheter insertion tray (A4314x4).

You asked the Plan to pre-approve the urological supplies. You say that you feel if you can change your catheter once per week you will not have urinary tract infections. The Plan denied your request. The Plan says the provider has not submitted documentation to substantiate medical necessity of more than one catheter insertion tray per month.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the urological supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the additional catheter insertion tray (A4314x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve the hearing aids. You say that you need hearing aids. The Plan denied your request. The Plan says you must receive your care from a network provider except for urgent or emergent care or no in-network provider is 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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve hearing aids to be provided by the requested out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says SNF care is
not medically reasonable and 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 the SNF services. Our reviewer says
that daily skilled services are not medically necessary. Our physician reviewer found that based on the
documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled
services are not required to establish a maintenance program or to prevent deterioration of the enrollee's
condition. The enrollee's care needs at this point are behavioral/custodial and, as a practical matter, can be
provided at a lower level of care (ex. home, long term 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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve SNF services.
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. You say that the enrollee needs a therapeutic continuous glucose monitor. The Plan denied your request. The Plan says the enrollee is not currently using insulin and therefore does not meet LCD criteria.

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 indicate that the enrollee does not uses insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833 LT/RT) and suspension sleeve (L2397 LT/RT) provided March 16, 2021 to March 17, 2021.

You asked the Plan to pay for the orthoses. You say that please review this claim due to current COVID-19 pandemic guidelines and reconsider accordingly. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician. The records do not sufficiently document the enrollee's condition to support the medical necessity for the billed supply code.

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 orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. 

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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833 LT/RT) and suspension sleeve (L2397 LT/RT) provided March 16, 2021 to March 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan.

You asked the Plan to pre-approve Rituxan. You say that you would like reconsideration because the requested
drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step
therapy exception criteria.

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 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 Rituxan. Our reviewer says that the
Plan requires a trial of drug Ruxience before they will approve the requested drug. The record does not indicate
that the member has tried and failed a trial of the Plan's required drugs. Our physician reviewer found based on
the medical records provided there is no indication that the plan's required drug would likely be less effective
and/or likely have adverse effects for the member.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have
to pre-approve Rituxan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy tablets.

You asked the Plan to pre-approve Ubrelvy tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Ubrelvy tablets are not covered under the enrollee's Medicare Part B benefit.

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 Ubrelvy tablets.

Benefits for Ubrelvy 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve physical therapy. You say that these sessions are helping, and you would like to continue with this provider. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental implant (D6010) for tooth #22 and tooth #27.

You asked the Plan to pre-approve the implants. You say that you do not understand why implants are not covered and feel they should be as they are necessary. The Plan denied your request. The Plan says implants are not covered by your 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, 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 a dental implant (D6010) for tooth #22 and tooth #27.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from September 21,
2020 to September 27, 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 submitted records do not support the billing of DRG 329 and diagnosis code C20.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with DRG 329 and diagnosis code C20 (malignant
neoplasm of rectum). 

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 submitted records do not support the billing of DRG 329 and diagnosis code C20. Our
physician reviewer found the enrollee had a diagnosis of locally advanced rectal cancer. He has a history of
hypertension but his blood pressure was well controlled. The enrollee was deemed to be at slightly increased
surgical risk given previous history of myocardial infarction. The enrollee was medically cleared for surgery.
He was medically cleared for and underwent surgery on September 21, 2020. The records do not support the
billed DRG and diagnosis code, as there is no documentation of major complications or comorbidities with the
procedure.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital services rendered from September 21, 2020 to September 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you were told that the Plan would pay 80%. You also say that orthotics will allow you to continue life with walking and taking care of your two grandchildren. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional resin-based composites - one surface, posterior (D2391) for teeth 19 and 31.

You asked the Plan to pre-approve resin-based composites. You say that you need the two fillings and need help with the payment. The Plan denied your request. The Plan says you have exhausted your benefit for fillings for the year.

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 one resin-based composite per year.

We looked at the file, and Medicare rules. The Plan provided documentation showing that you have already been approved for one resin-based composite on tooth 19. Based on this information, we determined that the Plan's rules frequency limit for resin-based composites would be exceeded with the requested additional fillings. Therefore, we decided that the Plan does not have to pre-approve the additional resin-based composites - one surface, posterior (D2391) for teeth 19 and 31.
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 you need to be fitted for the
stockings. 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 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 portable CPAP machine and supplies.

You asked the Plan to pre-approve a portable CPAP machine and supplies. You say that the enrollee wants a brand specific CPAP for portability. The Plan denied your request. The Plan says the clinical information received with the request does not indicate that the CPAP machine the enrollee currently has is not meeting her needs.

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 CPAP machine provided September 16, 2019. This CPAP serves the same purpose as a portable CPAP machine and supplies. The medical documentation shows the enrollee is doing well with the current CPAP and is compliant. The enrollee's CPAP is still under reasonable useful lifetime. Therefore, we decided that the Plan does not have to pre-approve a portable CPAP machine and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular nerve stimulator device.

You asked the Plan to pre-approve implantable neurostimulator, pulse generator, any type (L8679) and percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555). You say that this procedure is cleared by the FDA and is covered by Medicare. The Plan denied your request. The Plan says this service is not a covered Medicare benefit.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. This device is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve an auricular nerve stimulator device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you are in a wheelchair and unable to stand.
The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that this is a necessity for your health, and you do not want to fall again. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.