Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve breast implant removal surgery (19371).

You asked the Plan to pre-approve the surgery. You say that the surgery is medically necessary. The Plan denied your request. The Plan says that the procedure is cosmetic in nature and non-covered.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 surgery. Our reviewer says that the services are considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee had breast implants in the past. The record indicates that imaging studies demonstrate bilateral contained ruptures. The enrollee has severe contracture, Baker Grade IV, on the right breast with induration. The left breast has a Baker Grade II to III contracture. The medical records provided support the medical necessity and reasonableness. 

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 been met. Therefore, we decided that the Plan has to pre-approve breast implant removal surgery (19371).

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.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of home health skilled nursing care after September 15, 2021.

You asked the Plan to pre-approve the continuation of home health skilled nursing care. You say that you continue to need home health skilled nursing care. The Plan denied your request. The Plan says home health skilled nursing care is no longer medically necessary as the enrollee's needs are custodial in nature.

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 continuation of home health skilled nursing care. Our reviewer says that the requested home health skilled nursing care is not medically necessary. Our physician reviewer found that you are a 93-year-old male with a past medical history of urinary retention, pulmonary embolus, hypertension and hypothyroidism who has been receiving home health nursing services since April 2021. Based on the medical records provided there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. Your medical conditions are stable with no skilled nursing needs. Your needs at this point appear to be custodial. 

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 home health skilled nursing care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of home health skilled nursing care after September 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol.

You asked the Plan to pre-approve Tramadol. The Plan denied your request. The Plan says Tramadol is a self-administered drug. The Plan also says that this medication does not fall under Part B coverage.

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 Tramadol.

Benefits for Tramadol may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (D9310) to be rendered by a
prosthodontist.

You asked the Plan to pre-approve the consultation. The Plan denied your request. The Plan says your dental
plan does not pay for services done by this type of dental specialist.

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
covered when they are received by a dentist whose practice specializes in prosthodontic services. Therefore, we
decided that the Plan does not have to pre-approve a consultation (D9310) to be rendered by a prosthodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an application of desensitizing resin (D9911) and occlusal adjustment (D9951).
You asked the Plan to pre-approve the application of desensitizing resin and occlusal adjustment. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 an application of desensitizing resin (D9911) and occlusal adjustment (D9951).
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 this enrollee is more appropriate to move to LTACH to continue his care. The Plan denied your request. The Plan says criteria for admission to the LTACH 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 that in this case the enrollee remains on high flow oxygen and is continuing to improve. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. At this point, your care needs are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF services. You say that the SNF services are 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 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 the enrollee is medically stable after recent treatment for a Urinary Tract Infection and needs no daily skilled nursing care. Functionally, she is at a high level and does not require daily skilled therapies in an inpatient 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantable neurostimulator, pulse generator, any
type (L8679).
You asked the Plan to pre-approve the implantable neurostimulator. You say that this request is for an
implantable neurostimulator. You have attached a letter of medical necessity from the doctor as well as office
notes. The Plan denied your request. The Plan says this device is an electroacupuncture device places behind
the ear and is not.
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. Based on this information, we decided that Medicare rules for
coverage of the implantable neurostimulator have not been met. Therefore, we decided that the Plan does not
have to pre-approve the implantable neurostimulator, pulse generator, any type (L8679).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on September 15, 2020.
You asked the Plan to pay for the dental services. You say that you cannot sit in a chair or have local pain medication due to your medical condition. You say that you must have intravenous sedation for all work and the corrected bill should be reviewed. The Plan denied your request. The Plan says the 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen conserving device. 
 
You asked the Plan to pre-approve an oxygen conserving device. You say that you need this item. The Plan 
denied your request. The Plan says this item is not covered for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that the home use of oxygen to treat cluster 
headaches is not reasonable and necessary unless provided in the context of an approved clinical study.  
 
We looked at the file and Medicare rules. The records show that the oxygen device at issue has been requested 
to treat cluster headaches but do not show that you are enrolled in a clinical study. Based on this information, 
we decided that Medicare rules for coverage of an oxygen conserving device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an oxygen conserving device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because the member has compression on the spine causing paralysis in the lower extremities and will now need subacute rehab to transfer out of the hospital. The Plan denied your request. The Plan says the member's needs are custodial in nature.
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 admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found this beneficiary 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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve SNF admission
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (99100) provided on February 24,
2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee
Schedule indicates that payment for covered services are always bundled into payment for other services not
specified.
We looked at the file and Medicare rules. Procedure code 99100 is assigned a status indicator of "B" under the
Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into
payment for other services. No separate payment can be made for the anesthesia services (99100). 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 pay for the anesthesia services (99100) provided on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you require close daily oversight of care by a Physician in an inpatient setting. The Plan denied your request. The Plan says that documentation does not support that the your functional or medical status requires an intensive rehabilitation therapy program provided in an inpatient rehabilitation unit.
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. 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 were admitted for a below the knee amputation. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the member would be best served with SNF services as her next level of care. The Plan denied your request. The Plan says that the records do not support the need for daily therapy 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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary to recover so that you can continue to take care of yourself. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you are requesting does 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213), retainer crowns (D6740 x 3), pontics (D6245 x 3), fillings (D2332 x 3), and scaling in presence of generalized moderate or severe gingival inflammation (D4346).
You asked the Plan to pre-approve the dental services. You say that you need these recommended treatments. The Plan denied your request. The Plan says that 1 filling is covered per calendar year. The Plan says that the frequency limit has been reached. The Plan also says that partial denture, retainer crowns, pontics, and scaling in the presence of generalized moderate or severe gingival inflammation are not listed as covered services.
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 and fillings are listed as covered, the frequency limit has been reached. The record shows that the Plan approved 1 filling. Additionally, the requested partial denture, retainer crowns, pontics, and scaling in the presence of generalized moderate or severe gingival inflammation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213), retainer crowns (D6740 x 3), pontics (D6245 x 3), fillings (D2332 x 3), and scaling in presence of generalized moderate or severe gingival inflammation (D4346).