Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
You asked the Plan to pre-approve the ventilator. You say that the use of this device greatly reduces hospitalizations. The Plan denied your request. The Plan says there is a lack of medical necessity.
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 the ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee has chronic respiratory failure due to chronic obstructive pulmonary disease and obstructive sleep apnea. The record indicates that the enrollee settings are for AVAPS. These settings can be achieved with an appropriate BiPAP machine. The medical records do not demonstrate a specific requirement for ventilator capabilities beyond what the enrollee could achieve with a BiPAP machine with AVAP capabilities.
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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an out of network
(OON) provider.

You asked the Plan to pre-approve a consultation to be provided by an OON provider. You say that the services
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to
provide these services. Therefore, coverage criteria have not been met.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a consultation to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept Procedure for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that more research is needed to show safety and efficacy of the procedure.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The intracept procedure remains experimental for low back pain. More research is needed to show safety and efficacy of the intracept procedure. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept Procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialized lower limb prosthetic cover (L5962).

You asked the Plan to pre-approve the specialized lower limb prosthetic cover. You say that the specialized cover is medically necessary. The Plan denied your request. The Plan says the documentation does not support the requested item.

The Plan must follow Medicare rules. Medicare rules say that specialized covers are not covered for everyday usage in a typical environment. 

We looked at the file and Medicare rules. There was no documentation that the enrollee has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection afforded by a standard cover. Based on this information, we decided that Medicare rules for coverage of the specialized lower limb prosthetic cover have not been met. Therefore, we decided that the Plan does not have to pre-approve a specialized lower limb prosthetic cover (L5962).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift feature (E2300) for a power wheelchair.

You asked the Plan to pre-approve a seat lift. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item is statutorily non-covered.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered. 

We looked at the file and Medicare rules. The request is for a power seat elevation feature. Based on this information, we decided that Medicare rules for coverage of a seat lift have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift feature (E2300) for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have a diagnosis of chronic obstructive pulmonary disease (COPD) and the arterial blood gas testing results show carbon dioxide retention. There are no documented results of pulmonary function tests to confirm COPD. You have been on bi-level positive airway pressure (BiPAP) but there are no records of the settings or evidence of usage compliance. A ventilator is not covered when used as a BiPAP. The records do not support that the home ventilator is reasonable or medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scans of the chest, abdomen, and pelvis.
You asked the Plan to pre-approve CT scans of the chest, abdomen, and pelvis. You say that you would like reconsideration because the member has had steady weight loss with no change in diet or activity. The Plan denied your request. The Plan says the information received was not sufficient in supporting the medical necessity of the requested CT scans.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve CT scans of the chest, abdomen, and pelvis. Our reviewer says that the elements of the coverage rule are not satisfied. The requested services are not recommended. Our physician reviewer found the medical records do not indicate that any work up has been performed. The provided medical records are insufficient to establish the medical reasonableness and necessity of the requested 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 CT scans of the chest, abdomen, and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scans of the chest, abdomen, and pelvis.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services or skilled therapy services. There are no skilled services indicated. This enrollee does not require the services on an inpatient basis, only 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested home ventilator.

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 home ventilator. Our reviewer says that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found a home ventilator is considered not medically necessary. This enrollee has recurrent acute on chronic respiratory failure. There is a diagnosis of chronic obstructive pulmonary disease (COPD), although there is no confirmation with pulmonary function tests.

The medical records do not provide evidence on an arterial blood gas, done while the enrollee is awake and stable, showing CO2 retention. There is no documentation of BiPAP failure while at home and stable. Medicare does not cover a ventilator when used as BiPAP, and certain BiPAP devices can provide the AVAPS mode of support that has been ordered. Obstructive sleep apnea has not been excluded. 

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 7, 2021.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on 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 forthe dental services (D0210, D0150, D4342, D1110, D2391, D0274) provided February 10, 2020, through October 16, 2020 by a provider who has opted out of Medicare.You asked the Plan to pay forthe dental services. You say that you chose to have your dental work performed by dental students to help them complete their studies and reduce your costs for dental work.The Plan denied your request. The Plan says the provider who renderedthe services has opted out of Medicare and therefore the services are not covered.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 dental services when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original MedicareWe looked at the file and Medicare rules. The services at issuein this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore,we decided that the Plan does not have to pay forthe dental services (D0210, D0150, D4342, D1110, D2391, D0274) provided February 10, 2020, through October 16, 2020 by a provider who has opted out of Medicare.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted with chronic osteomyelitis and an infected sacral decubitus ulcer. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injections.

You asked the Plan to pre-approve sacroiliac joint injections. You say that the requested sacroiliac joint injections are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested sacroiliac joint injections.

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 sacroiliac joint injections. Our reviewer says that the enrollee does not meet criteria for the requested sacroiliac joint injections. Our physician reviewer found the enrollee has chronic low back pain. She has failed Epidural steroid injections as well as Facet joint injections. The request is for SI joint injections. There is no documentation of an NSAID trial. There is no documentation of Physical therapy. Therefore, at this time, the request is deemed 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 sacroiliac joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met and the enrollee can receive the needed care in the current hospital setting.
The Plan must follow Medicare rules. Medicare rules say that medical documentation must confirm that Medicare coverage criteria have been met. 
We looked at the file and Medicare rules. The case file shows that there were no medical records provided to support that LTACH care is medically necessary. The Plan made attempts to obtain these medical records. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks (MBBs).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MBBs are covered when specific criteria are met.

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 chronic low back pain after a motor vehicle accident. She had two sets of lumbar MBBs. The first set provided 60 percent pain relief and the second did not produce significant pain relief. The criteria for coverage are not met, as the enrollee did not achieve 80 percent pain relief from the previous injections. The repeat MBBs are 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-approve medial branch blocks (MBBs).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for a neurology provider.You asked the Plan to pre-approve the referral. You say that this is medically necessary.The Plan denied your request. The Plan says the requested provider is not contracted.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 out-of-network for a neurology provider.