Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out of network mental health services. You say that you would like reconsideration because you have tried several providers in the medical group but the care you received was not sufficient. The Plan denied your request. The Plan says there are several other psychologists or psychiatrists you can see within the appropriate distance from your residence.
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 the medical services to be provided by an out of network (OON) provider.
Your complaint about inadequate mental health services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq tablets for the enrollee.
You asked the Plan to pre-approve Myrbetriq under Medicare Part B. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under 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 Myrbetriq tablets for the enrollee.
Benefits for Myrbetriq 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can receive all of the care required at the current hospital.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. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The member is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The documentation does not support that at least 25 days of additional inpatient care are reasonably expected in this case. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.
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 requested IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 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 above. 
 
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is mobile with modified independence. The enrollee's care needs can be met 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 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 skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee's needs could be met at a lower level of care.
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 the records do not show that the enrollee has
identifiable skilled nursing or therapy service needs. He does not meet severity of illness or intensity of service
criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forgingival irrigation -per quadrant (D4921), periodontal scaling and root planing-one to three teeth per quadrant (D4342), bitewings -two radiographic images (D0272), intraoral -periapical each additional radiographic image (D0230) and periodontal maintenance (D4910) provided from September 8, 2018 through January 21, 2020.You asked the Plan to pay forthe dental services. You say that the services were medically necessary. You state neither you or the provider were informed prior authorization was required before services were rendered.The Plan denied your request. The Plan says the services are not a covered benefit under the plan.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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay forgingival irrigation -per quadrant (D4921), periodontal scaling and root planing -one to three teeth per quadrant (D4342), bitewings -two radiographic images (D0272), intraoral -periapicaleach additional radiographic image (D0230) and periodontal maintenance (D4910) provided from September 8, 2018 through January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forprovision of test materials and equipment for home INR monitoring provided from February 20, 2020 to March 10, 2020.You asked the Plan to pay forprovision of test materials and equipment for home INR monitoring (G0249). You say that the Plan should pay this claim.The Plan denied your request. The Plan says claims shall be allowed no more frequently than once every 4 weeks.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 provision of test materials and equipment for home INR monitoring (G0249) have not been met.GO249 contains material for four tests and should only be billed once a month. Therefore, we decided that the Plan does not have to pay forprovision of test materials and equipment for home INR monitoring provided from February 20, 2020 to March 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean EEG (95816).You asked the Plan to pre-approvethe EEG. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says there is no rationale for performing an EEG at this juncture.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 EEG. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member has no symptoms or complaints that would require evaluation with an EEG. It is unclear what (if any) diagnostic utility provision of an EEG would provide.In this context, the provision of an EEG would not be "furnished in accordance with accepted standards of medical practice." Nor would provision of this service otherwise reflect the generally accepted standards of care. Such testing would otherwise exceed the member's needs 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 EEG have not been met.Therefore, we decided that the Plan does not have to pre-approvean EEG (95816).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the air ambulance service provided on January 21, 2020. 
 
You asked the Plan to pay for the air ambulance service. You say that they did not have the facilities, equipment, or trained physicians to treat your medical condition. The Plan denied your request. The Plan says you requested the transfer to a preferred facility. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if you are transported to the nearest appropriate facility that can provide care. 
 
We looked at the file and Medicare rules. The record shows you were not transported to the nearest appropriate facility. Based on this information, we decided that Medicare rules for coverage of the air ambulance service have not been met. Therefore, we decided that the Plan does not have to reimburse you for the air ambulance service provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy.
You asked the Plan to pre-approve the Proton Beam Radiation Therapy. You say that you would like
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says
Proton Beam Therapy does not demonstrate a clinical advantage over other forms of treatment.
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 Proton Beam Radiation Therapy..
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found Proton Beam Therapy exceeds the need for this member and would not
be furnished in accordance with the accepted standards of medical practice for the diagnosis or treatment of the
member'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 Proton Beam Radiation Therapy. have not been met. Therefore, we decided
that the Plan does not have to pre-approve Proton Beam Radiation Therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the segmental pneumatic appliances (E0667 x 2) and the
pneumatic compressor (E0652) to be rendered by the out of network (OON) provider.
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says a network provider is available to provide the items
requested.
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 the segmental
pneumatic appliances (E0667 x 2) and the pneumatic compressor (E0652) to be rendered by the out of network
(OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapist.
You asked the Plan to pre-approve these services. You say that this provider has innovative treatment and
medication for your muscle spasm injury. 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. 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 physical therapist.
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 orthotics are necessary to help with balance because your toe was removed on one foot for infection. The Plan denied your request. The Plan says you do not have a condition for which orthotics are covered. 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. The 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found based on the medical records, although gradual improvement was noted during this
acute care stay, acute care appears still required. However, an additional 25 days of acute care is unlikely to be
necessary, based on the recent documentation. The enrollee does not require services at the proposed LTACH
that are not already available at the current acute care hospital. The vitals show the enrollee is not stable
enough for transfer and that acute care services are already being appropriately provided. Medicare coverage
criteria for transfer to an LTACH are not met. 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 for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa.You asked the Plan to pre-approvethese services. You say that the enrollee has severe osteoarthritis.The Plan denied your request. The Plan says the step therapy requirement is not met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has right knee osteoarthritis, confirmed on imaging. She has failed conservative treatment. She has not tried and failed the Plan's required drugs of Synvisc, Durolane, or Gelsyn-3. The records do not show that the required drugs would be less effective or contraindicated; therefore, the Euflexxa is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveEuflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you are not capable of living on your own without rehab.The Plan denied your request. The Plan says it is not reasonable to expect the enrolleeto participate in therapy 3 hours a day.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 physician reviewer found that you are at moderate independence for grooming, contact guard assist for upper body dressing, moderate assist for lower body dressing, and minimal assist for toileting, char transfers, and ambulating using a rolling walker. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies, such as physical and occupational therapy, but the documentation does not support that your functional level requires or can tolerate an 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 Medicarerules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveacute 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 SNF services. You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because you have shown progress in your condition and are making improvements in function. The Plan denied your request. The Plan says the continuation of skilled therapy sessions are no longer 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 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled services on an inpatient basis, in an SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of SNF services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered physical therapy services provided on November 5, 2019.You asked the Plan to pay for the non-covered physical therapy services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided are not covered when provided in a chiropractic setting.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the non-covered physical therapy services provided on November 5, 2019.