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

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not tried and failed oral drugs to treat their condition.  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 Prolia. Our physician reviewer found that the enrollee has a history of osteoporosis. In this case, there is no evidence of recent or previous osteoporosis related fractures. There is no documentation provided indicating that the enrollee has tried and failed oral bisphosphonates. There is no documentation provided indicating that the patient has contraindications to bisphosphonates. The review has determined that the documentation does not support that the coverage criteria have been met. The documentation does not support that the requested drug is medically reasonable or necessary for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Prostate Genomic testing provided to the enrollee on May 7, 2021.

You asked the Plan to pay for the testing. You say that this was medically necessary to help guide through the process of selecting the appropriate treatment. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested laboratory study. The test will not add to the enrollee's risk stratification. The review has determined that the services at issue in this case 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for Prostate Genomic testing provided to the enrollee on May 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on June 18, 2020.   You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that services of a physical/occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for interrogation device evaluations, remote up to 30 days
(G2066, 93298), provided on April 27, 2021, by an OON provider.

You asked the Plan to pay for interrogation device evaluations, remote up to 30 days. You say that the previous
date of services of the same patient on December 24, 2020, was paid without authorization. The Plan denied
your request. The Plan says this service was not authorized by the Plan. The Plan also says that they had
network providers available to perform the services at issue in the appeal.

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 Plan contract also says that you must obtain authorization
from the Plan prior to seeking care from an out-of-network provider.

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 interrogation device evaluations, remote up to 30
days (G2066, 93298), provided on April 27, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve cataract surgery (66984) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the cataract surgery. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available.  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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve cataract surgery (66984) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient.

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 services. Our physician reviewer found that from a nursing perspective, you received oral and inhaled medications, had stable vital signs, and was treated for pain. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a standby to contact guard assist for functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) 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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.  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 indicating medical necessity for LTACH services. 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 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. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on
July 1, 2021.

You asked the Plan to pay for out-of-network physical therapy. You say that the office, individual provider and
referring provider are participating providers with Medicare. You say that the therapist treated the member in
good faith with the medical care required and payment should be approved. The Plan denied your request. The
Plan says prior authorization for out-of-network services was not obtained.

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
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 physical therapy provided by an out-of-network
provider on July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair and related accessories.  You asked the Plan to pre-approve a shower chair and accessories. You say that these items are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is not a covered item under Medicare or the Plan rules.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. As the base shower chair is not covered, the related equipment is not covered as well. Therefore, we decided that the Plan does not have to pre-approve a shower chair and related accessories.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.  You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that these services are medically necessary for your condition. 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 hyperbaric oxygen therapy will be covered when the enrollee has an indication listed in the Medicare rules section.   We looked at the file and Medicare rules. The documentation indicates that you have a diagnosis of gross hematuria which is not among the covered indication listed in the NCD for hyperbaric oxygen therapy. Based on this information, we decided that Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

You asked the Plan to pre-approve the requested services. You say that the enrollee's pain affects her quality of daily life. The Plan denied your request. The Plan says this service is experimental.

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 requested services. Our physician reviewer found that the Intracept procedure remains experimental. More research is needed to show safety and efficacy. Therefore, the requested service is not considered 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions provided on July 14, 2021.

You asked the Plan to pay for the oral hygiene instructions. You say that the providers office did not explain or
indicate that this would not be covered. You say that you do not agree with the amount rejected or that is it
your responsibility. The Plan denied your request. The Plan says the service is not a covered 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 pay for the oral
hygiene instructions provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prochlorperazine.

You asked the Plan to pre-approve Prochlorperazine. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Prochlorperazine is not covered under the enrollee's Medicare Part B benefit as prescribed for the enrollee in this case.

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 Prochlorperazine.

Benefits for Prochlorperazine 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Glatopa.  You asked the Plan to pre-approve Glatopa. You say that the enrollee has been on this drug for many years and is doing great with this medication. The Plan denied your request. The Plan says the requested drug is not a covered 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 Glatopa.   Benefits for Glatopa 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the enrollee needs assistance with everyday activities. The Plan denied your request. The Plan says the enrollee does not require skilled nursing or rehab services on a daily basis as an inpatient.  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 services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and was treated for a urinary tract infection. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, the enrollee was at a moderate total assist level with functional mobility. She required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. She does not require skilled nursing or therapy services on a daily basis. She does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

You asked the Plan to pre-approve the requested services. You say that the enrollee's pain is disabling. The Plan denied your request. The Plan says there is little evidence to suggest this is an appropriate procedure for back pain.

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 requested services. Our physician reviewer found that the Intracept procedure is experimental. More research is needed to show safety and efficacy. Therefore, the requested service is not considered 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a prefabricated post and core (D2954), clinical crown lengthening (D4249), pulp cap (D3120), and amalgam (D2160) provided on July 15, 2021.  You asked the Plan to pay for the dental services. You say that when you were first looking for a dentist, this provider was listed as in-network according to the Plan's sources and the provider's office confirmed the network status. However, the provider's network status changed, and you only found out after this care was received. The Plan denied your request. The Plan says this provider does not participate with your Plan's dental network, and there are no benefits for dental services from out-of-network providers.  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. Dental services are covered with providers in the Plan's specified network only. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-network providers are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a prefabricated post and core (D2954), clinical crown lengthening (D4249), pulp cap (D3120), and amalgam (D2160) provided on July 15, 2021.   Your complaint about potential misinformation or a possible change in network status 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not require daily skilled nursing or therapy services in a SNF setting.

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 services. Our physician reviewer found that from a nursing perspective, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a standby assist to contact guard assist level for functional mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a manual wheelchair (K0005, E2211, E2201).  You asked the Plan to pre-approve the manual wheelchair. You say that the manual wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.   Records show that the manual wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (K0005, E2211, E2201).