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

We decided that the Plan does not have to pre-approve Atomoxetine 40 mg capsule.
You asked the Plan to pre-approve Atomoxetine. You say that this request is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 Atomoxetine 40 mg capsule.
Benefits for Atomoxetine 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 reimburse you for lodging and airfare provided from
November 19, 2020, though December 14, 2020.
You asked the Plan to reimburse you for lodging and airfare. The Plan denied your request. The Plan says lodging and airfare are not covered under your Plan benefits.
The Plan must follow Medicare rules. Medicare rules say that a supplemental benefit is an item or service not covered by original Medicare, that is primarily health related and for which the MA plan must incur a non-zero direct medical cost. We looked at the file, the Plan's rules and Medicare rules. The file shows that the Plan does not provide coverage for lodging and airfare for your cancer treatment. Therefore, we decided that the Plan does not have to reimburse you for lodging and airfare provided from November 19, 2020, though December 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin D testing and tuberculosis (TB) testing provided on January 7, 2021.
You asked the Plan to pay for the vitamin D and TB testing. You say that this testing should be paid. The Plan denied your request. The Plan says the testing provided was for screening purposes and not payable.
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 pay for the vitamin D and TB testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is a female with systemic lupus erythematosus and associated leukopenia being treated with prednisone, Plaquenil with benefit. Based on the provided documentation, there was no evidence of a prior low vitamin D or signs or symptoms suggestive of a TB infection or low vitamin D status to justify these additional tests. Therefore, without sufficient support made, the TB and vitamin D testing 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 vitamin D and TB testing have not been met. Therefore, we decided that the Plan does not have to pay for the vitamin D testing and tuberculosis (TB) testing provided on January 7, 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 for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided in 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. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided from April 16, 2020,
through April 30, 2020.
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says
prior authorization was not obtained by the provider or facility.
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
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for outpatient hospital services provided from April 16, 2020,
through April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit you had with an out-of-network
doctor on June 7, 2021.
You asked the Plan to waive the deductible for the out-of-network doctor visit. You say that you were advised
that this provider was in-network. You said that you would never have gone to an out-of-network provider if
you had known. The Plan denied your request. The Plan says this deductible was charged correctly. The Plan
says that their phone records show that you called on April 8, 2021, to ask about the network status of this
provider. The phone records show that the customer service agent was unable to contact the doctor because
their office was closed at the time. There is no evidence in the phone records that you were told that this
provider is in-network.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible which applies to out-of-network services.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which
applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the
time the services were received on June 7, 2021. Therefore, we decided that the Plan does not have to waive the
deductible for the office visit you had with an out-of-network doctor on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 19, 2020, by an OON
provider.
You asked the Plan to pay for the OON office visit. You say that the enrollee informed you that he was covered
under Medicare. You say that authorization was impossible to obtain, due to the enrollee misleading you with
the incorrect insurance information. You say that the care provided was medically necessary. The Plan denied
your request. The Plan says the services in dispute were provided out of network and without authorization.
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 had network providers
available who could have provided the items/services at issue in this appeal. 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 an office visit provided on September 19, 2020, by
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the fusion of pelvic joint using imaging guidance (27279).
You asked the Plan to pre-approve the fusion of pelvic joint using imaging guidance. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the fusion of pelvic joint using imaging guidance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for image guided sacroiliac (SI) joint fusion not met. The imaging studies show previous lumbar fusion and do not show SI joint degenerative joint disease or instability. SI joint fusion 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 the fusion of pelvic joint using imaging guidance have not been met. Therefore,
we decided that the Plan does not have to pre-approve the fusion of pelvic joint using imaging guidance (27279).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the weight loss clinic visits coded as 99212, 99070, 98962, 99211 and 84999 provided on January 2, 2021 to May 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the clinic visits. You say that you were not aware that a prior authorization was required for out of network provider. You were referred there by your cardiologist. You feel the cost was for health benefits and weight loss and should be covered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 had network providers available who could have provided the items/services at issue in this appeal. 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 weight loss clinic visits coded as 99212, 99070, 98962, 99211 and 84999 provided on January 2, 2021 to May 7, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Apligraf, per square centimeter (CPT code Q4101), for 
the enrollee.  

You asked the Plan to pre-approve the skin graft. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not indicate that the enrollee has chronic wounds 
that have failed standard treatment for at least a thirty (30) day period.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the skin 
graft. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the wound appears to be gradually improving and is not 
failing conservative treatment. Therefore, the enrollee does not meet criteria for grafting, and this request for 
Apligraf will be considered not medically necessary at this time. 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 skin graft 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Apligraf, per square 
centimeter (CPT code Q4101), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 multiple power option power wheelchair and attachments for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary for the enrollee. The Plan denied your request. The Plan says that there is no physical examination documented that corroborates and supports the recommendations stated by the evaluating physical therapist.
The Plan follows Medicare rules. Medicare rules say that a Group 2 multiple power option power wheelchair can be covered if LCD criteria is 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 these services are not medically reasonable and necessary for the enrollee in this case. There is a video visit in the provided records signed by the doctor dated July 27, 2021 that reports a mobility deficit that impairs participation in mobility related activities of daily living documentation, that the enrollee's mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair and documentation that the enrollee can safely operate a power mobility device. This documentation, however, does not include a physical examination by the prescribing provider supporting these statements. In addition, records from the prescribing provider do not document lower extremity edema or the presence of a cast or knee brace limiting knee flexion, history of dependence upon intermittent catherization for bladder management, use of a ventilator, or history of a current pressure ulcer or increased tone or spasticity to justify the requested elevating leg rests or combination power tilt and power recline seating system. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 multiple power option power wheelchair and attachments for the enrollee
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 this therapy. 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 you do not require the intensity of services provided at an IRF. Specifically, you
are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular
physician evaluation. Your care needs can be met 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 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: 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 ready to be transferred to an IRF. The Plan denied your request. The Plan says an IRF admission 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 that you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular
physician evaluation. Your care needs can be met 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 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: 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 needs inpatient rehabilitation to return to their prior level of function and return home safely. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. 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.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that these are necessary for you. 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) 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.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the present setting where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. 

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.