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

We decided that the Plan does not have to pre-approve bilateral breast reduction.

You asked the Plan to pre-approve bilateral breast reduction. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the requested procedure.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 

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 bilateral breast reduction. Our reviewer says that the elements of the coverage criteria are not satisfied. The requested service is not recommended. Our reviewer found the record indicates that you would benefit more from a mastopexy. The record provided does not indicate that conservative medical management has failed to treat your symptoms. The record supports that the procedure is cosmetic in nature. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral breast reduction have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral breast reduction.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the services are not 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 the services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee is
noted to have a tracheotomy, for which she has been receiving home health services for two years. The enrollee
is noted to tend to activities of daily living (ADLs) and mobilize well, but apparently can't care for the
tracheotomy. The enrollee has been receiving daily teaching regarding tracheotomy care, but apparently still
can't care for her tracheotomy. The enrollee is argued to require a daily nurse visit for health and safety, but
apparently manages the remainder of the time without an available caregiver or home health aide. The failure
to progress after two years of services makes ongoing services unreasonable. Assuming an actual daily need,
the required services are not intermittent. Furthermore, there is no documentation of a recent change in the
enrollee's health status or needs. As such, the request for ongoing daily home health skilled nursing services 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve home health services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 2, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were only at the dentist for your regular bi-annual cleaning, and you did not receive any other type of exam. The Plan denied your request. The Plan says your policy does not cover this procedure.
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 pay for the problem focused limited oral evaluation (D0140) provided on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a face-down positioning cushion.

You asked the Plan to pre-approve these services. You say that the item is vital to your success rate. The Plan denied your request. The Plan says the services are not covered.

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 face-down positioning cushion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lymphedema pneumatic compression with gradient
pressure sequential pneumatic compression with gradient pressure sequential pneumatic full leg pump to be
provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the lymphedema pneumatic compression pump. You say that the supplier is
the only one located in the enrollee's geographic area. The Plan denied your request. The Plan says the 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 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 lymphedema pneumatic compression with gradient pressure sequential pneumatic compression with gradient pressure sequential pneumatic full leg pump to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the incisional biopsy of oral tissue (D7286)
provided on September 30, 2021.
You asked the Plan to waive the copayment for the biopsy. You say that you were not aware that there was
going to be a charge for the biopsy. You also say that the office advised that everything was covered 100% and
you did not owe anything. The Plan denied your request. The Plan says when a service is a rendered, you have
a portion of the payment which is called coinsurance which gets applied to every claim for the services that you
receive. The Plan also says that you are responsible for this amount.
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, you are responsible for a 70%
coinsurance for oral surgery services. Therefore, we decided that the Plan does not have to waive the
copayment for the incisional biopsy of oral tissue (D7286) provided on September 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the member has stabilized medically
and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled
therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level
of care. Although further rehab services would be appropriate to improve function, as a practical matter, the
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member
does not have any parental medication, complex wound care or nutrition given via a feeding tube. She is
medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or
near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled
rehab services 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 admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with colon cancer
with syncope and dehydration, COVID-19 pneumonia and Myocardial infarction (MI). From a nursing
perspective, the enrollee received oral medications. The enrollee had stable vital signs. He was deemed stable
for discharge from a cardiac standpoint. Regarding rehabilitation services, the enrollee received physical
therapy and occupational therapy. By the dates in question, the enrollee was at a modified independent to
independent level with functional mobility including gait to 330 feet. The enrollee was at a modified
independent with activities of daily living.
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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 admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
You asked the Plan to pre-approve the Eliquis. You say that you would like reconsideration because the
requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not
covered 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 Eliquis.
Benefits for the Eliquis 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and
interpretation (D0367) provided on September 14, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you had two scans
done by two different dentists to determine if a tooth was causing the staph infection in your sinuses. You also
say that it was determined there was nothing wrong with your teeth. The Plan denied your request. The Plan
says this service is not a covered benefit under your dental 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 pay for the cone
beam computed tomography (CT) capture and interpretation (D0367) provided on September 14, 2021.
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 IRF care is medically necessary. The Plan denied
your request. The Plan says the enrollee does not meet Medicare criteria for coverage of IRF 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. Our
physician reviewer found while the patient has a need for physical and/or occupational therapy, there is no
documentation of a need for an intensive 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.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 50,000 unit Vitamin D capsules.
You asked the Plan to pre-approve the Vitamin D capsules. You say that you would like reconsideration
because the requested drug is medically necessary. The Plan denied your request. The Plan says the requested
drug is not covered 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 the 50,000 unit Vitamin D
capsules.
Benefits for the Vitamin D capsules 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 5mg Oxycodone tablets.
You asked the Plan to pre-approve the Oxycodone tablets. You say that you would like reconsideration because
the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is
not covered 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 the 5mg Oxycodone tablets.
Benefits for the Oxycodone tablets 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 140mg/ml inj Repatha Sureclick.
You asked the Plan to pre-approve the Repatha Sureclick. You say that you would like reconsideration because
the Repatha SureClick is medically necessary. The Plan denied your request. The Plan says the Repatha
SureClick is not covered 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 the 140mg/ml inj Repatha
Sureclick.
Benefits for the Repatha Sureclick 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.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied
your request. The Plan says you do not meet Medicare criteria for coverage of IRF 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.
Our physician reviewer found while you have a need for physical and/or occupational therapy, there is no
documentation of a need for an intensive 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional 50 miles of routine transportation.
You asked the Plan to pre-approve the additional 50 miles. You say that you would like reconsideration
because your provider is over 50 miles away. The Plan denied your request. The Plan says your benefit only
allowed 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation when the trip does not exceed 50 miles.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the
Plan does not have to pre-approve the additional 50 miles of routine transportation.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99348) provided on July 28, 2021 by an out-
of-network (OON) provider.
You asked the Plan to pay for the home visit. You say that the provided medical records support medical
necessity. The Plan denied your request. The Plan says the provider that performed these services is not in the
Plan's network. The Plan also says that the services performed were not authorized by the Plan.
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 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 for the home visit (99348) provided on July 28, 2021
by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy services.
You asked the Plan to pre-approve the home health physical therapy services. You say that you would like
reconsideration because the requested home health services are medically necessary. The Plan denied your
request. The Plan says the records show that you are independent for all tasks.
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 home health physical therapy
services. Our reviewer says that you do not have documented, ongoing, skilled PT needs. Our physician
reviewer found you are functioning at a level commiserate with a lower level or care. As such, the requested,
ongoing, home health physical therapy is 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 home health physical therapy services have not been met. Therefore, we
decided that the Plan does not have to pre-approve home health physical therapy services.