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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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.  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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for X-rays provided on July 23, 2021.  You asked the Plan to waive the copayments for X-rays. You say that you should not be charged per each X-ray and feel that it should be included under one. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $50 copayment for each X-ray.   You received two X-rays on July 23, 2021. Therefore, you are responsible to pay a $50 copayment per each X-ray. However, you are only being asked to pay the total amount of $94.86, which is less than the total copayment amount.   You have been asked to pay $94.86 for X-rays. 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 copayments for X-rays provided on July 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued services at a skilled nursing facility (SNF).  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says daily skilled services are no longer required.  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 services. Our reviewer says that the requested continuation of services are not medically reasonable or necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.  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 continued services at a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7321).  You asked the Plan to pre-approve an alveoloplasty. You say that this service is medically necessary so you can wear your dentures. The Plan denied your request. The Plan says this service is not covered under your benefits.  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 an alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7321).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  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 step therapy requirement is not met.    Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 postmenopausal osteoporosis. She has not tried and failed the Plan's required drugs, zoledronic acid and an oral bisphosphonate. The records do not show that the required drugs would be contraindicated or less effective; therefore, Prolia is 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 Prolia.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional 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 it is not likely that more home visits are needed.    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 records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. The enrollee is at a functional level that does not require ongoing professional skilled physical therapy. She is also independent in a home exercise 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain (70553), magnetic resonance angiography (MRA) of the head (70544), and MRA of the neck (70549) provided on April 24, 2020.  You asked the Plan to pay for the MRI of the brain, MRA of the head, and MRA of the neck. You say that you would like these services to be reprocessed. The Plan denied your request. The Plan says clinical records to support the medical necessity of these services have not been submitted.  The Plan must follow Medicare rules. Medicare rules say that MRIs and MRAs are covered only when they are medically necessary.  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 MRI of the brain, MRA of the head, and MRA of the neck. Our reviewer says that the MRI and MRAs were not medically reasonable and necessary. Our physician reviewer found the provider has not submitted any clinical records to support the medical necessity of these 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 the MRI of the brain, MRA of the head, and MRA of the neck have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain (70553), magnetic resonance angiography (MRA) of the head (70544), and MRA of the neck (70549) provided on April 24, 2020.
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 are eager to participate in 3 hours of therapy per day and need extensive assistance from nursing and therapy staff. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct and you can receive skilled nursing facility (SNF) care instead.  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 your nursing, medical, and rehabilitation needs does not require an acute inpatient hospital stay with an interdisciplinary approach to rehabilitation care. While you may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a raised toilet seat (E0244).  You asked the Plan to pre-approve a raised toilet seat. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says the requested item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature.   While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat (E0244).
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Brovana.  You asked the Plan to pre-approve Brovana. You say that this drug is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the step therapy criteria have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Brovana. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found that the Plan requires a trial of Perforomist (formoterol) before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) likely be less effective and/or likely have adverse effects for 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 Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0667).  You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for pneumatic compression devices have not been met.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. The item coded E0667 is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a neurology office visit to be provided by an OON provider.  You asked the Plan to pre-approve a neurology office visit. You say that you have been seeing this provider for years. The Plan denied your request. The Plan says this is available in-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 neurology office visit to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve therapeutic parenteral drug, single administration (D9610).  You asked the Plan to pre-approve the therapeutic parenteral drug. You say that you need this service covered to get your dentures done. The Plan denied your request. The Plan says this service is not covered under your benefits.  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 therapeutic parenteral drug, single administration (D9610).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lumbar medial branch blocks. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee has not failed other modalities for pain management.  The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications.   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 has a history of chronic multiple joint pain that includes the left shoulder, right knee, foot, ankle, low back pain due to lumbar spondylosis, and chronic neck pain. The documentation shows that the enrollee's pain is well controlled on Oxycodone. The documentation does not show other tried or failed modalities for management of low back pain. The records provide no documentation of a low back or low extremity exam prior to the request for the procedure. The review has determined that the lumbar medial branch blocks are not medically reasonable or necessary in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar medial branch blocks.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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.  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 a periodic oral evaluation (D0120) to be rendered by an OON provider.  You asked the Plan to pre-approve the periodic oral evaluation. You say that you would like to continue receiving dental services from this provider because you have been going there for a while now. The Plan denied your request. The Plan says services provided by an OON provider are not covered unless described in the Benefit Chart. The Plan also says that there are providers in your network that can provide the periodic oral evaluation.    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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a periodic oral evaluation (D0120) to be rendered by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) and bedside rails (E0305).  You asked the Plan to pre-approve a total electric hospital bed and bedside rails. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Bedside rails are not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) and bedside rails (E0305).