Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveeight additional physical therapy visits for the enrollee.You asked the Planto pre-approvethe services. You say that the enrollee has been reporting improvements.The Plandenied your request. The Plansaysthe notes do not show that that skilled physical therapy services are required to maintain, prevent, or slow further deterioration of the enrollee's functional status.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided, there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. The enrollee appears to have improved with therapy to the point of being contact guard assist for transfers and with increased lower extremity strength. Further formal therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point.
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 Plandoes not haveto pre-approveeight additional physical therapy visits for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea complete upper denture.You asked the Planto pre-approvethe denture. You say that this is medically necessary,The Plandenied your request. The Plansaysthe requested services exceed the maximum count allowed per period.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 dentures once every five years.Dentures were received less than five years ago on August 12, 2019. Based on this information, we decided that the Plan's rules for coverage of the denture have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea complete upper denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not need 
three hours of therapy a day, or physician monitoring three times a week. 
 
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 a contact guard assist level for standing up, minimal assist for walking using a rolling walker, 
standby assist for oral hygiene, and supervision for seating bathing and putting on socks. You do not require 
the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week 
of rehabilitative services and regular physician evaluation. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on June 30, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.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 forphysician services provided on June 30, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveOON services. You say that the injections give you great pain relief.The Plan denied your request. The Plan says your needs can be met in-network.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-approvemedical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bleach wipes/washcloths. 
 
You asked the Plan to pre-approve the items. You say that you had an infection and you need these to clean 
surfaces. The Plan denied your request. The Plan says this 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 bleach wipes/washcloths.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. You say that you need to regain your strength.The Plan denied your request. The Plan says there is no need for daily skilled therapy or nursing needs.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 services. Our physician reviewer found that you do not have documented skilled nursing needs. You donot have documented skilled therapy needs. You are ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is currently functioning below baseline. The Plan denied your request. The Plan says it is not reasonable to expect the enrollee will be able to fully benefit from the intensity of services of an IRF.
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 the enrollee was admitted to the acute hospital for surgical treatment of a hip fracture after a fall. His medical conditions are stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 30, 2020 by an outof network (OON) provider.You asked the Plan to pay forthe office visit. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says medical information does not support the need for an authorization to a non-plan provider, such as a lack of this specialty provider in the network or an urgent/emergent situation that requires the services of a non-planprovider.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 forthe medical services provided on January 30, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says services with this physician are not medically necessary because the services can be provided in-network.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 noexception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forsphere, bifocal, plano (V2200) progressive lens (V2781) tint, photochromatic, per lens (V2744) anti-reflective coating, per lens (V2750) purchased August 31, 2020.You asked the Plan to pay forthe vision services. You say that you received the wrong prescription for your eyewear and was still charged $327 for the pair. You feel that the claim should be covered because you received the wrong eyeglass prescription.The Plan denied your request. The Plan says the benefit has been exhausted.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when 1 routine eye exam and one pair of eyeglasses (or contact lenses) are covered after cataract surgery. You reimbursement for up to $120 towards the purchase of eyeglasses or contact lenses..We looked at the file and the Plan's rules. 1 routine eye exam and one pair of eyeglasses (or contact lenses) are covered after cataract surgery. You reimbursementfor up to $120 towards the purchase of eyeglasses or contact lenses. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay forsphere, bifocal, plano (V2200) progressive lens (V2781) tint, photochromatic, per lens (V2744) anti-reflective coating, per lens (V2750) purchased August 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process
stabilization/distraction device (Vertiflex device) (22869 and 22870).
You asked the Plan to pre-approve a Vertiflex device. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service is not medically 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 a Vertiflex device. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the device is experimental and more research is needed to show safety and efficacy.
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 Vertiflex device have not been met. Specifically, there is not enough
information on the device to show its safety and efficacy and, therefore, not reasonable or necessary. Therefore,
we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process
stabilization/distraction device (Vertiflex device) (22869 and 22870).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZilretta.You asked the Plan to pre-approveZilretta. You say that the requested Zilretta32mg injection is medically necessary.The Plan denied your request. The Plan says the requested Zilretta 32mg injection is not medically necessary.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 Zilretta. Our reviewer says that the requested Zilretta 32mg injection is not medically necessary. Our physician reviewer found Zilretta is an extended-release product intended to be used once per knee, per FDA indications, without repeat. The prescribing information indicates that following an evaluation to determine the safety of repeat administration of Zilretta determined that the data from this study are insufficient to fully characterize the safety of repeat administration of Zilretta. The enrollee received a Zilretta injection that provided 12 weeks of benefit.  A repeat injection of Zilretta is not supported.  There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to the guidelines.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met.Therefore, we decided that the Plan does not have to pre-approveZilretta.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOzempic.You asked the Plan to pre-approveOzempic. You say that the enrollee has had success on this medication.The Plandenied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.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-approveOzempic.Benefits for Ozempicmay be available under Medicare Part D.Contactthe 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-approvecontinuation of eight (8) additional PT visits (CPT Code 97139).You asked the Plan to pre-approvethe PT visits. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the services are not necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the patient's condition. The patient has had extensive therapy for this condition and the documentation does not indicate that her functional level requires the ongoing unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The patient was performing exercises correctly and the plan approved 2 more therapy visits to ensure HEP training. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slowfurther deterioration.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 PT visits have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinuation of eight (8) additional PT visits (CPT Code 97139).
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pre-approve flow cytometry for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a peripheral blood smear, nutritional evaluation, detailed family history, or detailed medication history.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the physician noted that b12 supplementation had recently been initiated, her family history was not indicative of any pattern, and likely medications such as NSAIDs were not taken anymore, leaving a need for further workup including peripheral smear, cbc, flow cytometry, folate, MMA (b12 deficiency), copper, all of which would be appropriate tests for this enrollee. 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 flow cytometry for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea spinal cord stimulator.You asked the Plan to pre-approvea spinal cord stimulator. You say that the requested spinal cord stimulator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested spinal cord stimulator.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 a spinal cord stimulator. Our reviewer says that the enrollee does not meet criteria for the requested spinal cord stimulator. Our physician reviewer found the enrollee has chronic low back pain and a history of Colon Cancer. She takes NSAIDs for pain. She has had epidural steroid injections and RFA of the lumbar medial branches but continues to have pain. A CT scan showed L1 compression fracture and L4-L5 disc narrowing. She has psychological clearance for a SCS trial. She does not have a history of back surgery or any other evidence based indication for a SCS trial. She has not had a trial of intra-thecal opiates or other medications. The enrollee does not have an evidence based indication for a SCS trial. There are several other interventions available to the enrollee.  The requested procedure is not medically reasonable or 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 a spinal cord stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approvea spinal cord stimulator