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

We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the
SNF services are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare
coverage criteria for the requested SNF services.

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 you do not have any parental
medication; complex wound care or nutrition given via a feeding tube. Your physical function is at or near your
baseline and you can receive services 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 the Skilled Nursing Facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that you need to get into rehabilitation as soon as possible because your surgery is coming up and surgery will not be scheduled until you test negative for Coronavirus. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you and/or your provider are requesting do not meet the requirements for approval.  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 based on the documentation provided, the health Plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. skilled nursing facility/sub-acute rehabilitation).  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 IRF admission and services.
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 lumbar compression fracture status post kyphoplasty. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee was at a supervision/stand by assist level for functional mobility including gait to 100 feet.  There are no identifiable skilled nursing service needs. There are 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intravascular Ultrasound followed by angioplasty and stenting with sedation.

You asked the Plan to pre-approve an Intravascular Ultrasound followed by angioplasty and stenting with sedation. You say that the requested Intravascular Ultrasound followed by angioplasty and stenting with sedation is medically necessary. The Plan denied your request. The Plan says the requested Intravascular Ultrasound followed by angioplasty and stenting with sedation is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an Intravascular Ultrasound followed by angioplasty and stenting with sedation. Our reviewer says that the requested Intravascular Ultrasound followed by angioplasty and stenting with sedation is not medically necessary. Our physician reviewer found the documentation does not support the medical necessity of the treatments in question. There is no evidence of whole leg swelling or other findings on the available studies suggesting significant proximal venous occlusive disease. The enrollee has been prescribed compression stockings however there is documentation that he had been using them for only 5 days. There has been enough time to evaluate if current treatment has been effective. Based on the available documentation the reasonableness and medical necessity of vascular ultrasound and angioplasty cannot be supported. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intravascular Ultrasound followed by angioplasty and stenting with sedation have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intravascular Ultrasound followed by angioplasty and stenting with sedation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226).  You asked the Plan to pre-approve the mandibular partial denture. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 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 pre-approve a mandibular partial denture (D5226).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.  You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.  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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with dementia, diabetes, depression and hypertension. From a nursing perspective, the enrollee received oral medications and insulin. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy, speech therapy, and occupational therapy in the SNF.  By the dates in question, the enrollee was at an independent to supervision/stand by assist level with functional mobility including gait to 150 feet. The enrollee required varying assist with activities of daily living. She tolerated a pureed diet.  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 the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the sleep study.  You asked the Plan to pre-approve the sleep study. You say that you would like reconsideration because the member meets criteria for the requested sleep study. The Plan denied your request. The Plan says the requested sleep study is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the sleep study. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a repeat in-facility sleep study would require a significant change in symptoms, weight, or other medical circumstances which was not evidenced in the provided documentation. Therefore, this request for repeat sleep study is not sufficiently supported in the 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 sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve the sleep study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a bilateral positive airway pressure (BiPAP) device.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says records were not received from the doctor.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   Despite multiple attempts by the plan, medical records were not received for this request. It cannot be determined that the requested device is appropriate for you. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral positive airway pressure (BiPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the second opinion office visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the second opinion office visit. You say that the out-of-network provider is closer to your home. 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 the second opinion office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC).

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 criteria for coverage are not 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 (PWC).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health skilled nursing visits for the enrollee.  You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not support the need for a skilled nurse to make more visits.  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 visits. Our reviewer says that the requested home health skilled nursing visits are not medically reasonable or necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy). As such, the requested ongoing home health skilled nursing services are 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing visits for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.  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 admission is not 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted records show that you were admitted to the hospital and received physical therapy. The note dated December 26, 2021 states you need modified assistance with transfers. You declined physical therapy on December 27, 2021. The records show that you have no skilled nursing needs. You do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous transcatheter closure of congenital interatrial communication 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 Medicare covers services and items that are considered reasonable and necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the review of the current medical literature indicates that this service or item is considered to be reasonable and necessary when certain conditions are met. The records do not show that this request is 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 percutaneous transcatheter closure of congenital interatrial communication for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral cervical medial branch blocks.

You asked the Plan to pre-approve bilateral cervical medial branch blocks. You say that the requested bilateral cervical medial branch blocks are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested bilateral cervical medial branch blocks.

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 bilateral cervical medial branch blocks. Our reviewer says that the enrollee does not meet criteria for the requested bilateral cervical medial branch blocks. Our physician reviewer found the enrollee has chronic axial neck pain. She had an epidural steroid injection which did not provide pain relief. She has undergone 2 diagnostic sets of Medial branch blocks with 80% pain relief. The request is for a third set of facet injections. The enrollee is a candidate for radiofrequency ablation (RFA), not repeat injections. The requested repeat injections are 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 bilateral cervical medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral cervical medial branch blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the standard glucose test strips.  You asked the Plan to pre-approve the standard glucose test strips. You say that you would like reconsideration because the requested supplies are medically necessary. The Plan denied your request. The Plan says the member has a functioning insulin pump and continuous glucose monitor.  The Plan must follow Medicare rules. Medicare rules say that claims for a BGM and related supplies, billed in addition to an approved CGM device and associated supply allowance, will be denied.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the standard glucose test strips have not been met. Specifically, the record indicates that the member has a continuous glucose monitor. The CGM replaces any standard blood glucose monitor so all related supplies remain denied. Therefore, we decided that the Plan does not have to pre-approve the standard glucose test strips.
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 continuous glucose monitor (CGM) and supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device.  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 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 continuous glucose monitor (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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six surgical extractions (D7210 x6), therapeutic parenteral drugs (D9612), and deep sedation/general anesthesia (D9222).

You asked the Plan to pre-approve the surgical extractions, therapeutic parenteral drugs, and deep sedation/general anesthesia. You say that your teeth are broken off at the gums and your mouth is infected. The Plan denied your request. The Plan says these services are not covered 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. The only type of extraction that is covered under your plan is simple extractions. Therefore, we decided that the Plan does not have to pre-approve six surgical extractions (D7210 x6), therapeutic parenteral drugs (D9612), and deep sedation/general anesthesia (D9222).