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 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 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 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 would not be advantageous clinically at this
time and will be considered 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 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 an office visit (99213) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that this care is medically necessary. The Plan denied your request. The Plan says they have in-network providers available.
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 an office visit (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot receive the proper
treatment in a lower level of care and requires transfer to an LTACH. The Plan denied your request. The Plan
says the criteria for admission to an LTACH are not met. The enrollee is currently receiving appropriate
inpatient acute care, and these services have not been denied. The enrollee's status is stable and improving, and
there are no issues for which an LTACH would offer a therapeutic advantage at this time. 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 record indicates that the enrollee is improving. The enrollee is continuing to
receive acute care services, and these have not been denied. The medical record does not indicate that the
enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.
The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation oncology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that the enrollee has a tumor causing a lung obstruction. The Plan denied your request. The Plan says there are in-network providers available.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve radiation oncology services to be provided by an out-of-network (OON) provider.
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 IRF criteria as per Medicare
guidelines. You say that IRF care is the most appropriate setting for the enrollee to reach his maximum
rehabilitation potential under the direct care and supervision of a skilled rehabilitation team and physical
medicine and rehabilitation physicians. The Plan denied your request. The Plan says the care needed does not
need to be done in an IRF. The Plan says that the records do not show that the enrollee needs an intensive team
approach for care. The Plan says that the enrollee can safely receive the 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 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. The enrollee
was admitted for a diverting colostomy and surgical debridement of a deep sacral pressure ulcer. The enrollee's
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 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.
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 a combination of pembrolizumab, cisplatin, and
gemcitabine.
You asked the Plan to pre-approve pembrolizumab, cisplatin, and gemcitabine. You say that you are appealing
with supporting research. The Plan denied your request. The Plan says the denial of authorization for this drug
combination is correct, because studies have not proven that these drugs are helpful for treatment of the
enrollee's condition.
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 pre-approve pembrolizumab, cisplatin, and
gemcitabine. Our reviewer says that the enrollee does not meet the Medicare criteria for this chemotherapy
combination. Our physician reviewer found there is no role for chemotherapy and immunotherapy in
transitional cell cancer. This combination is not Food & Drug Administration (FDA) approved for the
enrollee's diagnosis. It is not supported by one of the major drug compendia or by clinical research that appears
in a Medicare-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 pembrolizumab, cisplatin, and gemcitabine have not been met. Therefore, we
decided that the Plan does not have to pre-approve a combination of pembrolizumab, cisplatin, and
gemcitabine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home mechanical ventilator.
You asked the Plan to pre-approve the ventilator. You say that the service should be covered. The Plan denied your request. The Plan says request for a home mechanical ventilator set in AVAPS mode that could be delivered by BiPAP is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found there was no clear record of the patient having failed home BiPAP with back up rate and AVAPS to help justify a home ventilator unit. Therefore, this request for such will be considered not medically necessary at this time based on the provided documentation.
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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home mechanical ventilator.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the crown (D2790) provided on February 4, 2021.
You asked the Plan to pay for the crown. You say that you would like to appeal this service. The Plan denied
your request. The Plan says that this service is not covered.
The Plan must follow Medicare rules. Medicare rules say that the health plan must provide you with a clear and
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under
your plan contract including applicable conditions and limitations and any other conditions associated with the
use or receipt of the benefits.
We looked at the file and Medicare rules. The record shows that you received a crown (D2790), which was
denied by the Plan as not being a covered benefit. The 2021 Evidence of Coverage states that crowns are
limited to 1 per tooth every 5 years. The contract does not clearly state which crowns are not covered, and there
was no documentation provided showing that you have exhausted this benefit. You reasonably believed the
crown you received would be covered because it is listed as a covered service. Based on this information, we
decided that Medicare rules for coverage of the crown have been met. Therefore, we decided that the Plan has
to pay for the crown (D2790) provided on February 4, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: 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 the SNF services. You say that the clinical documentation provided supports the need for SNF care. The Plan denied your request. The Plan says SNF care is medically necessary.
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 the SNF services. 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. The enrollee is ambulating household distances and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, 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 the 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide an additional 36 routine transportation trips.
You asked the Plan to provide additional routine transportation. You say that the enrollee requires this transportation to get to and from their necessary appointments. The Plan denied your request. The Plan says up to 36 one-way trips are covered per calendar year. Additional trips are not covered.
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 a maximum of 36 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide an additional 36 routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that you are unable to poke your fingers due
to severe Raynaud's syndrome. The Plan denied your request. The Plan says that you do not meet criteria for
coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day, use insulin with at least three daily injections and require frequent
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we
decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that
the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) additional home skilled nursing visits.
You asked the Plan to pre-approve four (4) additional home skilled nursing visits. You say that you would like
the plan to reconsider their denial. 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 four (4) additional home skilled nursing
visits. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician
reviewer found the enrollee has been receiving home health services after a laparoscopic cholecystectomy. The
documentation does not support that further skilled nursing services are required to effectively provide
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not
document any acute or unstable medical conditions or changes in medication or treatment which would
necessitate further skilled nursing home health visits beyond what have already been provided. Therefore, the
enrollee does not meet criteria for the requested 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 four (4) additional home skilled nursing visits have not been met. Therefore, we
decided that the Plan does not have to pre-approve four (4) additional home skilled nursing visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation trips.
You asked the Plan to pre-approve the routine transportation trips. You say that you need transportation to the requested offices due to a possible knee replacement. The Plan denied your request. The Plan says the requested routine transportation trips are not covered under the enrollee's benefit because the distance to the requested locations exceeds the benefit allowance.
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 each one-way trip does not exceed 50 miles.
We looked at your request, the records in the case file, and the rules. The records show that the locations you are requesting transportation to are more than 50 miles from your home address. 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 routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Ultra test strips for diabetes to be provided by a non-preferred provider.
You asked the Plan to pre-approve the One Touch Ultra test strips. You say that the test strips should be covered. The Plan denied your request. The Plan says it reached out to obtain more information from the enrollee and the provider but received no response.
Medicare rules say that plans can require enrollees to get care from preferred providers. The contract with the Plan says that the Plan has to pre-approve care from a non-preferred provider only when there is evidence from the physician in the documentation indicating why the non-preferred provider is necessary.
The requested provider in this case is not a Plan preferred provider with the Plan. The Plan has preferred 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 One Touch Ultra test strips for diabetes to be provided by a non-preferred provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (heel insert).
You asked the Plan to pre-approve foot orthotics. You say that you have medical circumstances that necessitate the heel insert. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics or inserts) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (heel insert).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories.
You asked the Plan to pre-approve a group 3 power wheelchair and related accessories. You say that this equipment is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity.
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically
necessary. The Plan denied your request. The Plan says 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 the skilled nursing facility services. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does
not require skilled nursing or therapy services on a daily 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 skilled nursing facility services have not been met. Therefore, we decided
that the Plan does not have to pre-approve skilled nursing facility services.