Persius/hicric huggingface dataset:
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 enrollee's needs would be best met in an LTACH setting. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been 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 that the enrollee appears to be more stable but there are not enough weaning attempts documented and the enrollee has critical cardiomyopathy that requires ongoing treatment that continued treatment at the current facility is recommended until more stable. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to LTACH is not supported or medically necessary due to it not being clinically advantageous. Transfer may be considered when treatment has completed and the enrollee is more stable.  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 the office services (CPT code(s): 99204 and 99214) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the out-of-network office services. You say that this doctor is a part of the medical team who worked on you before, so you feel more comfortable with going to this doctor. The Plan denied your request. The Plan says they have not seen you before; therefore, you are not in a current treatment plan. The Plan states there are appointments available within a week and is within the Medicare allowable distance and time.

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 office services (CPT code(s): 99204 and 99214) to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ten (10) additional PT visits.  You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically 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 ten (10) additional 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has had instruction in a home exercise program. Additionally, the enrollee is to get an MRI of the knee due to more pain and the results of this study are not documented to indicate that skilled therapy is appropriate. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further 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 ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intravenous moderate sedation first 15 minutes (D9239) and intravenous moderate sedation each subsequent 15-minute increment (D9243).  You asked the Plan to pre-approve intravenous moderate sedation. You say that you have abscesses that are infected. You also say you have a nerve disorder with chronic pain and need the sedation. The Plan denied your request. The Plan says the service at issue is not a covered benefit with your 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. Therefore, we decided that the Plan does not have to pre-approve intravenous moderate sedation first 15 minutes (D9239) and intravenous moderate sedation each subsequent 15-minute increment (D9243).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an active water circulation pump with cold compression.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says cryotherapy needs can be met with traditional ice packs.  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 documentation does not reveal extenuating factors on a physical exam or indications that your needs cannot be met with an at-home local ice pack application. The request for a specialized pump exceeds your medical needs. 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 an active water circulation pump with cold compression.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided with a total knee arthroplasty (27487).  You asked the Plan to pre-approve acute inpatient hospital care. You say that you have severe medical conditions and cannot proceed with this surgery without an inpatient admission. The Plan denied your request. The Plan says they have agreed to cover the knee arthroplasty as the surgery is medically necessary; however, you are currently medically stable and there is no documentation to support that an inpatient admission that will span at least two midnights is necessary. The surgery is approved as an ambulatory procedure.  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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that a right total knee arthroplasty is planned. A request for inpatient admission was made for this elective surgery. The records do not show that your conditions are unstable or suggest that you would likely have a prolonged recovery from this typically ambulatory procedure. The records do not support that you would require hospital services that would likely cross 2 midnights for this procedure.   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 not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided with a total knee arthroplasty (27487).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76337).  You asked the Plan to pre-approve the diagnostic service. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says 3D pictures are not medically necessary. MRI had been approved and 3D pictures can be provided from the MRI.  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 diagnostic service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality is medically reasonable and necessary for the enrollee in this case.  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 diagnostic service have not been met. Therefore, we decided that the Plan does not have to pre-approve 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76337).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Privigen (J1459).  You asked the Plan to pre-approve Privigen. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met.  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 Privigen. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee has a diagnosis of inclusion body myositis. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Privigen have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Privigen (J1459).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve crowns (D2740), core buildups (D2950) and canal preparation and fitting of preformed dowel or post (D3950).  You asked the Plan to pre-approve these services. You say that these services are necessary. The Plan denied your request. The Plan says that these services are not covered by your 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. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740), core buildups (D2950) and canal preparation and fitting of preformed dowel or post (D3950).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 10 skilled nursing visits, 15 minutes each (G0299).  You asked the Plan to pre-approve the skilled nursing visits. You say that the enrollee has experienced a recent weight loss. You also say that the enrollee is in need to diabetic teaching, medication teaching, along with monitoring of surgical site. The Plan denied your request. The Plan says the requested number of visits for diabetes assessment and education are not medically necessary as you were educated on this chronic condition in the past and no recent changes.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 skilled nursing visits. Our reviewer says that the requested 10 skilled nursing visits are not medically necessary. Our physician reviewer found the provided documentation shows the enrollee does not have documented skilled nursing needs. Therefore, the reviewer found that the requested skilled nursing visits are not medically necessary or reasonable.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing visits have not been met. Specifically, the file does not indicate that the enrollee requires skilled services. Therefore, we decided that the Plan does not have to pre-approve 10 skilled nursing visits, 15 minutes each (G0299).
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 enrollee is stable and suitable for transfer to an LTACH. The Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not meet the requirements for approval.  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 that there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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: 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 these services are medically reasonable and necessary. The Plan denied your request. The Plan says the rules for LTACH care have not been 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 the patient is a 68-year-old male who was admitted to the acute care hospital with heart failure exacerbation and acute respiratory failure with cardiogenic shock complicated by bacteremia, acute on chronic anemia, acute kidney injury, atrial flutter/fibrillation, and dysphasia. Recent notes show that he is still receiving a dobutamine drip, increased oxygen requirements, and cardiac workup is underway.  In this case, the patient appears to be unstable and requiring additional workup and stabilization treatment until transfer is considered. Additional acute care services can be safely administered at the current facility in the meantime. The patient does not require services at the LTACH that are not already available at the current facility. Furthermore, there are no services at the LTACH that the patient requires that are not already available and covered at the current facility. In conclusion, transfer to an LTACH is not supported or medically necessary due to it not being clinically advantageous. Transfer may be considered when treatment has completed and the patient is more stable.  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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fiorinal.

You asked the Plan to pre-approve Fiorinal. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.

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 Fiorinal.

Benefits for Fiorinal 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you don't have to be in a hospital for rehab but can go to SNF rehab to continue with your progress. The Plan denied your request. The Plan says that all the services you need are offered at the inpatient rehab facility.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99202) electrical stimulation (unattended) (97014) provided on July 23, 2021 to August 13, 2021.  You asked the Plan to pay for the chiropractic visits. You say that it was your assumption that this new chiropractor would be covered.  You had no idea he was not participating. This was the only chiropractor that could take on a new patient at this time. The Plan denied your request. The Plan says these services are not covered under the Plan benefits.  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 outpatient office visit (99202) electrical stimulation (unattended) (97014) provided on July 23, 2021 to August 13, 2021.