Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that a lower level of care cannot provide the
interdisciplinary team approach needed. The Plan denied your request. The Plan says the enrollee does not
require an intensive team to reach his functional goals.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 care hospital for lumbar decompression and fusion. His medical
problems are stable. There are no complex nursing needs. He does not require treatment by multiple therapies
in an intensive rehabilitation therapy program. While the documentation does support a need for physical
and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve face shields.
You asked the Plan to pre-approve face shields. You say that you are appealing the denial of the face shields
because you cannot wear a mask. The Plan denied your request. The Plan says a face shield does not meet the
definition of durable medical equipment as it is not primarily and customarily used to serve a medical purpose.
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 face shields.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Crow boot (L4631) to be provided by an out-of-network provider.
You asked the Plan to pre-approve a Crow boot. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for out-of-network care 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 item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve a Crow boot (L4631) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that you need your current prosthetic fixed. You also say that you have an infected tooth that needs to be pulled but is attached to your prosthetic. The Plan denied your request. The Plan says this service is not covered under your dental benefit.
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 a mandibular partial denture (D5214).
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 LTACH care is medically necessary for recovery. The Plan denied your request. The Plan says based on Medicare guidelines and the information provided about the enrollee's condition, the requirements for an admission to an LTACH are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided indicating medical necessity for admission to an 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: Surgery
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve shoulder surgery.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee has not attempted physical therapy or activity modification.

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 requested services. Our physician reviewer found that the enrollee is being treated for pain in right shoulder. She presented with pain along the anterolateral aspect of the shoulder that tends to be worse with activity, especially lifting the arm up overhead or tucking her shirt in behind her back. An exam reveals passively, the shoulders can be taken through a fairly good arc of motion. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. She is noted to have had physical therapy, although the dates are not clearly documented nor the number of attended sessions and if she had any benefit. Results from a home exercise program or activity modification is not demonstrated. In addition, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology.

There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for shoulder surgery repair of ruptured musculotendinous cuff and claviculectomy, 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve shoulder surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra heavy-duty manual wheelchair.
You asked the Plan to pre-approve an extra heavy-duty manual wheelchair. You say that you feel this item is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that an extra heavy-duty wheelchair is covered if the beneficiary weighs more than 300 pounds. We looked at the file and Medicare rules. The requested item is only covered for enrollees that weigh over 300 pounds. Review of the file shows that you do not weigh more than 300 pounds. Based on this information, we decided that Medicare rules for coverage of an extra heavy-duty manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra heavy-duty manual wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Belbuca.

You asked the Plan to pre-approve Belbuca. You say that the enrollee is trying to decrease the chance of respiratory depression. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Belbuca.

Benefits for Belbuca 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the alert or alarm device, not otherwise classified (A9280).
You asked the Plan to pre-approve the alert or alarm device. You say that the enrollee has been in constant treatment, however it is difficult to determine when he presents syncope. Therefore, it is recommended that the enrollee should us an alert device for any emergency. The Plan denied your request. The Plan says the requested item is not considered durable medical equipment because it is not primary medical in nature and is considered a self-help or precautionary type equipment.
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 the alert or alarm device, not otherwise classified (A9280).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled physical therapy (PT) visits (G0151 x 18), and
skilled nursing visits (G0299 x 18).
You asked the Plan to pre-approve 12 additional PT visits and 18 skilled nursing visits. You say that the
requested services are medically necessary. The Plan denied your request. The Plan says the requested services
are not medically necessary.
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 12 additional PT visits and 18 skilled
nursing visits. Our reviewer says that the home health services are not medically necessary. Our physician
reviewer found the documentation does not support that you require skilled nursing services or additional
skilled rehabilitation (rehab) services to provide treatment that is medically necessary. The reviewer found that
you do not require skilled nursing or additional rehab services to effectively provide treatment, care, and/or
services in order to improve your condition, perform a maintenance program to maintain your condition and/or
prevent deterioration. The reviewer found that you have been medically stable without any recent exacerbations
of chronic medical problems or hospitalizations. The reviewer found that you do not have skilled nursing
needs. Therefore, the reviewer found that the requested home health services are 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 12 additional PT visits and 18 skilled nursing visits have not been met.
Specifically, the file shows that you do not require skilled nursing or additional rehab services to effectively
provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to
maintain your condition and/or prevent deterioration. Therefore, we decided that the Plan does not have to preapprove
skilled physical therapy (PT) visits (G0151 x 18), and skilled nursing visits (G0299 x 18).
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 have documented skilled
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not
shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition.
At this point, the enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level
of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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 pre-approve a surgical implant placement (D6010), bone replacement graft (D7953), implant supported porcelain/ceramic crown (D6065) and a custom fabricated abutment (D6057).

You asked the Plan to pre-approve the dental implant services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by your dental benefit.

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 a
surgical implant placement (D6010), bone replacement graft (D7953), implant supported porcelain/ceramic crown (D6065) and a custom fabricated abutment (D6057).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided on May 10, 2021.
You asked the Plan to waive the copayment for an x-ray. You say that You say that you received the J&J/Janssen Coronavirus (Covid-19) vaccine which caused some side effects, including muscle weakness. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for each x-ray. You have been asked to pay a $15 copayment for an x-ray. X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies Benefit Category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray provided on May 10, 2021.
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 enrollee is medically stable for transfer to a lower level of care.
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 physician reviewer found that the enrollee was admitted to the LTACH on August 14, 2021. She was weaned off ventilator support. She was deemed stable for discharge. There is no documentation provided indicating medical necessity for continued LTACH services. 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. Therefore, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional physical therapy visits.
You asked the Plan to pre-approve 2 additional physical therapy visits. 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 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 2 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of your condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have 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. You have been instructed in and is compliant in a home exercise program. 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 your 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 2 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Interferon (J9214) provided on March 29, 2021.

You asked the Plan to pay for the Interferon. You say that you would like this claim to be reconsidered for
medical necessity. You also say that you believe this service was appropriate based on the enrollee's past
medical history. The Plan denied your request. The Plan says experimental or investigational services are not
covered.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
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 pay for the Interferon. Our reviewer says that the
requested treatment is considered experimental. Our physician reviewer found the requested use of Interferon
(J9214) is not FDA-approved for the enrollee's diagnosis. Our reviewer also found that the use of Interferon is
not supported by one of the major drug compendia or by clinical research that appears in a Centers for
Medicare & Medicaid Services approved medical journal.

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 Interferon have not been met. Therefore, we decided that the Plan does not
have to pay for the Interferon (J9214) provided on March 29, 2021.