Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jardiance for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that this drug is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Jardiance for the enrollee.
Benefits for this drug 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for pneumonia and encephalopathy. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (CPT code 99284) provided to the enrollee on October 7, 2019.
You asked the Plan to pay for the emergency department visit. You say that the claim should be paid. The Plan denied your request. The Plan says they did not receive a primary carrier's Explanation of Benefits. The Plan states the enrollee had a primary insurance from September 1, 2019, through April 26, 2021.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer.
However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has [indicate the plan's method of coordination]. As the secondary insurer, the Plan cannot be held responsible for the emergency department visit until the primary insurer has denied the claim for these services. Review of the records show the Plan verified the enrollee had a primary insurance from September 1, 2019, through April 26, 2021. We are upholding the decision to deny payment as it is the provider's responsibility to bill the Primary Group Health Plan or any liability insurance before submitting the claim to the enrollee's plan. Therefore, we decided that the Plan does not have to pay for the emergency department visit (CPT code 99284) provided to the enrollee on October 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services.
You asked the Plan to pre-approve the requested services. You say that your current dentures are deteriorating.
The Plan denied your request. The Plan says the services are not a covered 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.
The file shows that 2D imaging, crowns, core buildups, compete upper dentures, partial lower dentures, and
extractions were requested. Although the Plan offers a dental benefit in excess of Medicare coverage, the
requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pre-approve dental services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower.
You asked the Plan to pre-approve the shower. You say that this is medically necessary. The Plan denied your
request. The Plan says this item is not considered durable medical 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 a walk-in shower.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a DyAnsys Neurostimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied
your request. The Plan says this is specifically non-covered by Medicare as an electro-acupuncture device.
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is
not a covered Medicare benefit.
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 stimulator. Our reviewer says that
Our physician reviewer found [state the medical finding(s) upon which the physician based his/her conclusion]
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 stimulator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a DyAnsys Neurostimulator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve varicose vein treatments.

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 varicose vein treatments 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 records do not support the use of the many requested procedures. The Plan has approved coverage of chemical adhesive ablation of a truncal vein and sclerotherapy of multiple veins. There is no documentation suggesting that the approved procedures have been performed or failed to help the enrollee. There is no documentation that the enrollee has been sufficiently symptomatic with activity limitation despite conservative efforts for at least six weeks after previous treatments have been attempted. The services are therefore 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 varicose vein treatments.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 7, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from September 7, 2021, forward. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 psychiatric care from September 7, 2021, forward. Our reviewer says that you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 7, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond September 7, 2021, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 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 psychiatric care from September 7, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 7, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA).

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 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 services are not medically necessary. Our physician reviewer found the enrollee has advanced right knee osteoarthritis. She had diagnostic genicular nerve blocks that provided 80 percent pain relief for six hours. The use of RFA of the genicular nerves is the subject of ongoing clinical trials and is considered experimental/investigational in nature and is therefore 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 genicular radiofrequency ablation (RFA).
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 you need an intensive inpatient rehabilitation in order to return to your prior level of function. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Medical problems are stable. There are no complex nursing or rehabilitation needs. 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. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.
You asked the Plan to pre-approve hearing aids. You say that hearing aids are medically necessary because you need to communicate with people who are wearing masks as you are unable to read lips if masks are worn. The Plan denied your request. The Plan says your hearing tests must be poor and must meet certain Plan requirements. Your test results did not meet the Title 22 requirements on either ear.
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 hearing aids. Our reviewer says that the requested hearing aids are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that you have a hearing deficit of 18 decibels in the left ear and 30 decibels in the right ear. You do not have mild to moderate hearing loss is both ears. The requested service is to accommodate the inability to read lips when individuals are wearing masks. The requested service is not medically necessary and reasonable, as defined by Medicare rules, for your specific clinical situation. The elements of the coverage rule 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 hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit system (K0108) for an ultralightweight wheelchair.
You asked the Plan to pre-approve a transit system. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transit system (K0108) for an ultralightweight wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric scooter.
You asked the Plan to pre-approve an electric scooter. You say that you feel this electric scooter is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the enrollee does not have a mobility deficit that impairs your participation in MRADLs, the enrollee's condition can be improved by a walker, cane or manual wheelchair and the documentation does not support that the enrollee can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve an electric scooter
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 the enrollee meets the criteria and would benefit from the level of care provided at an IRF. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met, and the enrollee can safely receive the necessary care in a less intensive setting.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical removal of residual tooth roots, teeth 3, 5, 6, 7, 8, 11, 13, 21, 22, 23, 26, 27, (D7250 x12).
You asked the Plan to pre-approve the dental services. You say that the enrollee has extensive periodontal disease for which he was advised the need to all be extracted. Please consider approval of full extractions as recommended by his dentist. The Plan denied your request. The Plan says the benefit has been exhausted for the 2021 Plan year.
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. Per page 84 of the health plan contract, the plan covers three procedure codes of non-surgical or surgical extractions per calendar year. The records show that the Plan approved for teeth 9, 12 and 28 on approval dated June 18, 2021. 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 surgical removal of residual tooth roots, teeth 3, 5, 6, 7, 8, 11, 13, 21, 22, 23, 26, 27, (D7250 x12).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
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 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 these services. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has right-sided back pain after a tennis tournament on June 27, 2021. He has a home exercise program in place. He has made progress with pain reduction and doing exercises on his own since beginning physical therapy. The requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. He does not require the unique skills of a professional therapist to safely and effectively provide treatment. The services are not part of a maintenance program and are not needed to maintain the enrollee's current condition or prevent 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.