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

We decided that the Plan does not have to pre-approve oral enteral nutrition for the enrollee.
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 covered.
The Plan must follow Medicare rules. Medicare rules say that oral enteral nutrition is not covered. We looked at the file and Medicare rules. The services at issue are oral enteral nutrition. Therefore, we decided that the Plan does not have to pre-approve oral enteral nutrition for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the upper extremity and elbow joint.
You asked the Plan to pre-approve the MRI. You say that the enrollee should have this imaging to determine the issue causing her arm pain. The Plan denied your request. The Plan says the enrollee has not tried conservative therapy such as medications or physical therapy. As such, this imaging is not appropriate at this time.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the requested imaging is not shown to be medically reasonable and necessary. Our physician reviewer found there is no clinical rationale for the requested MRI of the right upper extremity. There is no evidence of extremity mass or adenopathy with increased risk for malignancy. There is no documentation of physical therapy, chiropractic treatments, or medically directed home exercise program for four weeks in the last six months. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the upper extremity and elbow joint.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show a need for an intensive team of providers.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains within a predicted period. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveArmodafinil 50mg tablet for the enrollee.You asked the Planto pre-approvethe tablet. You say that this is medically necessary.The Plandenied your request. The Plansaysoral medications are considered self-administered drugs.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 Plandoes not haveto pre-approveArmodafinil 50mg tablet for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided from October 6, 2019 to October 13, 2019.You asked the Plan to pay forhome infusion therapy. You say that this is a valid code.The Plan denied your request. The Plan says this code is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided from October 6, 2019 to October 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea vacuum socket system.You asked the Plan to pre-approvea vacuum socket system. The Plan denied your request. The Plan says that this 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 vacuumsocket system. Our reviewer says that a vacuumsocket system is not medically reasonable and necessary for the enrollee in this case. You have been active with the current prosthesis when it was not broken or not fitting anymore due to change in the size of the residual limb. If properly fitted to meet your residual limb needs a similar socket that you have been wearing should be advised as you do not meet the Medicare criteria for vacuum-assisted socket system. Our physician reviewer found that your condition does not meet criteriafor coverage of a vacuumsocket system.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 vacuumsocket system have not been met.Therefore, we decided that the Plan does not have to pre-approvea vacuum socket system.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay fortherapeutic exercises provided on November 11, 2019 by an out of network (OON) provider.You asked the Plan to pay fortherapeutic exercises. You say that treatment in our office was directed by a participating provider.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not recommend these services. The Plan says that the referring provider is out-of-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 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 has network providers available who can provide 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 fortherapeutic exercises provided on November 11, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on July 16, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records; therefore the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on July 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean epidural steroid injection (ESI) for the enrollee.You asked the Plan to pre-approvethese 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 ESIs 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 bilateral radicular pain and scoliosis. Her last physical therapy was three years ago. There is no documentation of other recent conservative therapies. There is no recent trial of conservative therapy, a home exercise program, or medication trials. The requested ESI does not meet the criteria for coverage and is not 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-approvean epidural steroid injection (ESI) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forhearing aid batteries (V5267x2) purchased October 6, 2019.You asked the Plan to pay forthe hearing aid batteries. You say that since you received the cochlear implant, Medicare has covered the cost each time you replaced the batteries. Without batteries to operate the device you are totally deaf on the right side.The Plan denied your request. The Plan says that to receive in-network benefits for routine hearing services member's must use an in-network provider.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for hearing aids both in-network and out-of-network.  Hearing aids are limited to a $500 maximum benefit every 36 months combined in-network and out of network. Members receive a free battery supply during the first 3years both in-network and out-of-networkPer the plan contract, members can receivehearingservices from both in-network and out-of-network providers. Membersalsoreceive a free battery supply during the first 3 years both in-network and out-of-network. Based on this information, we decided that the Plan's rules for coverage of the hearing aid batteries have been met.Therefore, we decided that the Plan has to pay forhearing aid batteries (V5267x2) purchased October 6, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea tier exception for Tacrolimus 1mg capsule for the enrollee.You asked the Planto pre-approvethe tier exception. You say that this is medically necessary.The Plandenied your request. The Plansaysa tier exception cannot be granted for a Part B medication.The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs.The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea tier exception for Tacrolimus 1mg capsule for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe documentation fails to indicate that the enrollee requires the available of rehab nursing care 24 hours per 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is medically stable, with no evidence of need for supervision by the PMR physician, or needs acute rehab nursing care. The enrollee is ready to be discharged home functionally requiring just supervision. IRF admission is not medically necessary based on her current functional status and medical stability.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CardioMEMS HF system for the enrollee.You asked the Plan to pre-approvethe system. You say that this is medically necessary.The Plandenied your request. The Plan says this is not covered under the current Medicare Category B Investigational Device Exemption Requirements.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessaryare 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 system. Our reviewer says that the requested system is not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 system have not been met.Therefore, we decided that the Plan does not have to pre-approvea CardioMEMS HF system for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAranesp.You asked the Plan to pre-approveAranesp. You say that the records provided support the need for the drug being requested.The Plan denied your request. The Plan says the enrollee does not have chronic kidney disease, cancer related conditions, or myelodysplastic syndrome. The Plan says that the enrollee does not have a medical need for thedrug being requested.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has a medical history that includes macrocytosis and worsening pancytopenia. There is no diagnosis of chronic kidney disease, malignancy or myelodysplastic syndrome noted in the provided medical records. The medical records provided does not support that Aranesp is safe and effective for the 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 Aranesp have not been met.Therefore, we decided that the Plan does not have to pre-approveAranesp.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean inpatient skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveinpatient skilled nursing facility care. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient skilled nursing facility admission.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 inpatient skilled nursing facility care. Our reviewer says that youdo not meet criteria for coverage of an inpatient skilled nursing facility admission. Our physician reviewer found that you do not require skilled nursing or skilled therapy services on a daily basis. Additionally, you do 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 inpatient skilled nursing facility carehave not been met.Therefore, we decided that the Plan does not have to pre-approvean inpatient skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for1additional periapical x-ray (D0230) provided on December 6, 2019 by the out of network dentist.You asked the Plan to pay for1 additional periapical x-ray. You say that the provider's office advised that they accept your plan. You say they also advised that the services would be covered. You say that you received a bill a few weeks after your appointment showing that none of the services were covered. You also say that you are on a limited incomeand cannot afford to pay the bill.The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit has been exceeded.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 coverageand periapical x-rays are a covered service, the frequency limit of 1 periapical x-ray per calendar year has been exceeded.The record shows that the Plan paid for 2 periapical x-rays that you received on December 6, 2019.Therefore, we decided that the Plan does not have to pay for1 additional periapicalx-ray (D0230) provided on December 6, 2019 by the out of network dentist.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided to the enrollee on August 25, 2018.
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan denied your request. The Plan says that coverage can be authorized at the observation level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for inpatient hospital services provided to the enrollee on August 25, 2018.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from April 20, 2019 through April 22, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from April 20, 2019 through April 22, 2019.