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 enrollee will clearly benefit from IRF care to
optimize his level of functioning prior to returning home. The Plan denied your request. The Plan says based on
Medicare guidelines, the requested IRF services 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 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.
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 the 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) services.

You asked the Plan to pre-approve PBRT services. You say that the records provided support the medical
necessity of PBRT services. The Plan denied your request. The Plan says PBRT is not the standard of care for
prostate cancer and should only be performed within the context of a prospective clinical trial.

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 PBRT services. Our reviewer says that
PBRT services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is insufficient prospective, long-term clinical data available to determine whether or not proton
beam radiation therapy for prostate cancer is superior, inferior or equivalent to external beam radiation therapy,
intensity-modulated radiation therapy (IMRT), brachytherapy with regards to safety and efficacy. The most
recent American Urological Association (AUA) guidelines state that PBRT offers no clinical advantage over
other forms of definitive treatment and should not be offered outside of a clinical trial 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 PBRT services have not been met. Therefore, we decided that the Plan does not
have to pre-approve proton beam radiation therapy (PBRT) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you do
not meet the criteria.
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. In this case, there are insufficient medical records to show that you
perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and
require frequent self-adjustment of insulin dosage based on the blood glucose testing results. The record shows
that the Plan made several attempts to obtain the necessary documentation without success. 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 a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied
your request. The Plan says the records do not document any trials of conservative treatment.
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 injections. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has another pain generator in the failed back surgery syndrome.
Therefore, the criteria for these blocks are not met, and the request is deemed 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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve facet joint injections for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional occupational therapy.

You asked the Plan to pre-approve occupational therapy. You say that occupational therapy services are needed to facilitate independence with activities of daily living, promote quality of life, increase endurance/balance, and increase safety. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Plan has approved an additional 4 weeks of therapy and additional therapy beyond that is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 occupational therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the Plan. The enrollee has had prior extensive therapy and has already been instructed on safety, transfers, and ambulation. The enrollee was approved for some additional therapy then can transition to 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 occupational therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional occupational therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is a medical
necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested item
have not been met.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify
for oxygen solely based on blood gas studies obtained during sleep.
To qualify for home oxygen, the patient must meet one of the following blood gas levels:
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during
sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for
patients who have hypoxia symptoms during exercise;
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of
dependent edema, pulmonary hypertension, or erythrocythemia.
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air,
there is a rebuttable presumption of non-coverage.
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 a portable oxygen concentrator. Our
reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician
reviewer found that the medical record does not provide information on oxygenation that indicates a need for
supplemental oxygen. The case record contains an overnight oximetry report that is illegible. Resting room air
oxygen saturations are greater than 92%. There is no exercise oximetry demonstrating hypoxemia correctable
with oxygen provided through an oxygen conserving device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140),
panoramic radiographic image (D0330), incisional biopsy of oral tissue-soft (D7286), and inhalation of nitrous
oxide/analgesia, anxiolysis (D9230) provided July 6, 2021.
You asked the Plan to pay for the limited oral exam, panoramic x-ray, incisional biopsy and nitrous oxide. You
say that you were told this claim could be processed as a medical issue instead of a dental one. The Plan denied
your request. The Plan says these services are 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 pay for the limited oral evaluation - problem focused
(D0140), panoramic radiographic image (D0330), incisional biopsy of oral tissue-soft (D7286), and inhalation
of nitrous oxide/analgesia, anxiolysis (D9230) provided July 6, 2021.
Your complaint about potentially being provided misinformation by a plan representative is not a valid appeal
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare
does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6752) for teeth # 8, 10 and 11, and a pontic (D6242) for tooth # 9.

You asked the Plan to pre-approve the dental services. You say that you have no teeth to eat with. You also say that you are in pain. The Plan denied your request. The Plan says the services are not covered.

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. The Plan covers the dental services when the services are medically necessary and reasonable. 

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 dental services. Our reviewer says that the requested retainer crowns and pontic are not medically necessary. Our physician reviewer found the provided documentation does not show that you have a disorder, physical or neurological, that would prevent the use of a removable prosthesis. As there is no supporting documentation regarding any disorder preventing the use of a removable appliance, there would be no coverage for the requested anterior bridge as plan criteria has not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6752) for teeth # 8, 10 and 11, and a pontic (D6242) for tooth # 9.
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 exceed the criteria for LTACH
admission. The Plan denied your request. The Plan says the clinical information provided does not support the
medical necessity of care in an LTACH based on criteria. The required care could be provided at an alternate
setting.
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 you are receiving appropriate care at the present acute care hospital. You do not
require services at the LTACH that are not available at the acute care hospital where you are currently
receiving care. There are no services available at the LTACH that you require 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 your diagnosis and condition 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: 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 clinical information provided supports the need
for care in an IRF. The Plan denied your request. The Plan says the intensive rehabilitation program 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 the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee was admitted for coronary artery bypass grafting. The enrollee's medical problems are stable. There
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for
an intensive rehabilitation program. There is not a reasonable expectation that the 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: 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 needs additional time in a
hospital to get him off a ventilator. The Plan denied your request. The Plan says the denial of authorization for
LTACH service is correct.
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 the enrollee is improving but requires ongoing acute care services. The enrollee
continues to receive acute care services and these have not been denied. The record does not indicate that the
enrollee requires services that are not currently being received but that would be available at the LTACH.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural injection.

You asked the Plan to pre-approve epidural injection. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this is not medically necessary.

The Plan follows Medicare rules. Medicare rules state that epidural steroid injections may be covered if certain criteria are 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 epidural injection. Our reviewer says that the enrollee does not meet the Medicare criteria for an epidural steroid injection. Our physician reviewer found there is no imaging documented in the records submitted. Therefore, the request is deemed not medically reasonable and 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 epidural injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural injection.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low dose computed tomography (CT) scan of the lungs
for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says the request cannot be approved.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 pre-approve the scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found the record indicates
that the enrollee ceased smoking over seventeen years ago. The elements of the coverage criteria are not
satisfied.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve low dose computed tomography (CT) scan of the lungs for the enrollee.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance service, advanced life support, emergency transport
(A0427), and ground mileage (A0425) provided on March 28, 2021.
You asked the Plan to pay for the transportation services. You say that the auto insurance has already processed
the claim. The Plan denied your request. The Plan says that the claim was processed correctly.
The Plan must follow Medicare rules. Medicare rules say that Medicare secondary payment amounts are
determined by the excess of the actual charge minus the primary payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the transportation services have been met. The file shows that you billed $902 for the services in
this case. The file shows that the primary insurance paid $799.64. $902 - $799.64 = $102.36. The Plan did not
provide the Medicare allowed amount for these services. Thus, Medicare secondary payment amounts are
determined by the excess of the actual charge minus the primary payment, or $102.36. Therefore, we decided
that the Plan has to pay for the ambulance service, advanced life support, emergency transport (A0427), and
ground mileage (A0425) provided on March 28, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.