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. Medically necessary services can be provided in a different 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (K0800).

You asked the Plan to pre-approve a power operated vehicle. You say that your current scooter was provided for free so another should be covered. The Plan denied your request. The Plan says the requested item is duplicative.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you have a power scooter. a power scooter serves the same purpose as a power operated vehicle. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (K0800).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lorazepam.

You asked the Plan to pre-approve Lorazepam. You say that the enrollee has been on this medication for years. The Plan denied your request. The Plan says this medication does not fall under the Part B 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 Lorazepam.

Benefits for Lorazepam 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 heavy duty power operated vehicle and accessories.
You asked the Plan to pre-approve a Group 1 heavy duty power operated vehicle (K0801) and accessories. You say that the enrollee has difficulties completing daily activities inside the home. The Plan denied your request. The Plan says the enrollee is independent with all ADLs and MRADLs therefore he does not meet criteria.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show that the enrollee has a mobility deficit that impairs participation in MRADLs, his condition cannot be improved by a walker, cane or manual wheelchair or he can safely operate the PMD being requested. There is no face-to-face or home assessment documentation. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 heavy duty power operated vehicle and accessories.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you need to have skilled care for wound care. The Plan denied your request. The Plan says there is no daily skilled nurse or therapist need.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a SNF setting. Services in the home with home health care or a long-term care facility on a part time basis as needed appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 25, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your request. The Plan says evidence in the published peer-reviewed scientific literature is lacking; long-term safety and efficacy has not been established despite U.S. Food and Drug Administration (FDA) approvals for most of these devices.

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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22869 and 22870), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226) and clinic service (T1015).
You asked the Plan to pre-approve the mandibular partial denture and clinic service. You say that you lost your bottom partials and need a new set. The Plan denied your request. The Plan says the submitted information does not demonstrate systemic or chronic illness that will jeopardize your life or cause continued deterioration of health if this benefit is not approved.
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 contract says that pre-existing removable prosthesis (includes partial and full dentures) must be at least five years old and unserviceable to qualify for replacement. The clinic service is also not a covered benefit under the dental plan. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5226) and clinic service (T1015).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).

You asked the Plan to pre-approve the dental item. You say that you need an occlusal guard. The Plan denied
your request. The Plan says occlusal guard is not listed as a covered service.

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 occlusal guard is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an
occlusal guard (D9944).
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 want therapy through an IRF to get stronger, walk better, get more confident in yourself and have your medications re-evaluated. The Plan denied your request. The Plan says you would not benefit from an intensive rehabilitation program, you do not have complex medical management needs, and do not require supervision by a rehabilitation physician.

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for thyroid stimulating hormone (TSH) (CPT code 84443) provided to the enrollee on March 18, 2021.
You asked the Plan to pay for the service. You say that you are working on obtaining network status. The Plan denied your request. The Plan says this is a duplicate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. This is denied due as a duplicate service to the same service billed on claim #820210841612079 billed by another provider on the same date of service. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for thyroid stimulating hormone (TSH) (CPT code 84443) provided to the enrollee on March 18, 202
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you cannot drive that far for 30 days. The Plan denied your request. The Plan says there are in-network providers available to provide these services.
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 specialist services to be provided by an out-of-network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee needs a CT scan for lung cancer screening. The enrollee had one done 1 year ago. The Plan denied your request. The Plan says the enrollee does not meet the criteria due to the presence of lung abnormalities on imaging.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above-described criteria. We reviewed the file and the Medicare rules. We find that the records show there is a presence of lung abnormalities on imaging. You must not have signs or symptoms of lung disease. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested brand of glucose monitor test strips.

You asked the Plan to pre-approve this specific brand of glucose monitor test strips. You say that you have used the requested brand for several years and would like to continue. The Plan denied your request. The Plan says you have not tried their formulary alternatives.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The record shows your provider did not indicate a medical reason you are unable to use the Plan's preferred brand of test supplies. Based on this information, we decided that Medicare rules for coverage of a specific brand of glucose monitor test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the requested brand of glucose monitor test strips.
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 enrollee is ready to transfer to LTACH for continued improvement. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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 acute care hospital where he 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyaluronan or derivative (Supartz).

You asked the Plan to pre-approve the Supartz. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for additional treatment.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 pre-approve the Supartz. Our reviewer says that Supartz is not medically reasonable and necessary for the enrollee. Our physician reviewer found there is documentation that the enrollee has a diagnosis for which Supartz has been found to be medically reasonable but the records do not document prior improvement with viscosupplement injections (as required by the health plan's prior authorization criteria) to justify re-injection with a viscosupplement. Our reviewer found that the enrollee's last viscosupplement injection was at least six months ago. Our physician reviewer also found that based on the medical records provided there is no documentation that the enrollee had less pain after the last viscosupplement injection such that they have been able to function better or do not need as much pain medicine. 

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 Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve hyaluronan or derivative (Supartz).
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 you would like the LTACH services covered. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care; does not require transfer to LTACH.
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 acute care hospital where he 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture with a flexible base (D5225) and inhalation of nitrous oxide/analgesia (D9230).
You asked the Plan to pre-approve the denture and analgesia. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
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 partial upper denture with a flexible base (D5225) and inhalation of nitrous oxide/analgesia (D9230).