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

We decided that the Plan does not have to pre-approve treatment with Triazolam tablet.  You asked the Plan to pre-approve Triazolam tablet. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Triazolam tablet.   Benefits for Triazolam tablet 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 Botox.
You asked the Plan to pre-approve Botox. You say that the requested Botox is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Botox.
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 Botox. Our reviewer says that the enrollee does not meet criteria for the requested Botox. Our physician reviewer found the enrollee has a diagnosis of gastroparesis and acute gastritis without bleeding. The enrollee does not meet the LCD criteria for approval of Botox. In addition, the enrollee does not have an off-label indication for Botox supported by evidence-based guidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150) provided September 23, 2021.  You asked the Plan to pay for the comprehensive oral exam. You say that you would like the benefit applied to the first comprehensive exam re-allocated to this exam. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the comprehensive oral exam once every three plan years.  We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive exam was previously covered on April 29, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150) provided September 23, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.  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 enrollee does not meet criteria for IRF admission. 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 cervical spine surgery. 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, in 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.  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: Favorable

 We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after February 1, 2022.  You asked the Plan to pre-approve SNF care. You say that continued SNF care is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria.  The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.  We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before February 1, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after February 1, 2022.   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: 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.  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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee appears to not be improving significantly and should only require additional short-term acute care that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. There are no services that the enrollee requires that are not already available and covered at the current facility. Transfer is not medically necessary as it would not be clinically advantageous.     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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories/multiple power options.  You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical need for multiple power options included with K0861 group 3 power wheelchair.  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.   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 wheelchair. Our reviewer says that  Our physician reviewer found based on the medical records provided, there is no documentation that multiple power options with power seat elevation, power elevating leg rest, power tilt and power recline, expandable controller, harness and electronic connection meet Medicare criteria for necessity. The records do not document high risk for skin breakdown, need for bladder catherization or the presence of muscle spasticity to meet criteria for power tilt and recline. The power seat elevation feature is non-covered by Medicare. No edema is documented to meet criteria for the power leg elevation feature. Provided records document that the enrollee is independent with feeding thus indicating she has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. A group 3 power wheelchair with no power options appears to be indicated 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 the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories/multiple power options.
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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving appropriate care in the current hospital and there is no advantage in transferring to an LTACH at this time. The enrollee can stay in the hospital until they are safe for transfer or discharge.  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 record indicates that the enrollee is critically ill with confusion and hypotension and requires acute care services. The enrollee is receiving continued acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the use of bone marrow aspirate (20939) for a spinal fusion procedure.  You asked the Plan to pre-approve bone marrow aspirate. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.  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 bone marrow aspirate. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that bone marrow aspirate remains experimental in cases of spinal fusion. More research is needed to demonstrate the safety and efficacy of the requested procedure.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve the use of bone marrow aspirate (20939) for a spinal fusion procedure.
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 clinical information provided supports the need for SNF care to help the enrollee reach maximum function. The Plan denied your request. The Plan says SNF care is not medically necessary or beneficial for the enrollee.
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 there is no evidence that the enrollee requires skilled nursing services. The records do support that skilled therapy services are required. However, skilled therapy services are not required on a daily basis. The enrollee does not require the services needed on an inpatient basis only 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 admission to an inpatient psychiatric facility.  You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the request is not medically necessary because the records received show that the condition has improved, and you are no longer a threat to yourself or others.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.     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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on a review of the records provided, it was not expected that this enrollee would improve in a reasonable period of time beyond the dates in question, as you were not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors, while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as there were no abnormal behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate.  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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.  You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there are no skilled nursing or skilled therapy needs that can only be provided on an inpatient basis.  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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing or skilled therapy needs. The enrollee is ambulating household distances, and tending to ADLs with minimal supervision. Care needs, 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve a home ventilator.  You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that there is already a functioning ventilator, and a second ventilator would serve essentially the same purpose as the existing ventilator.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 ventilator. Our reviewer says that the requested second ventilator is medically reasonable or necessary. Our physician reviewer found you have amyotrophic lateral sclerosis (ALS), a generalized neuromuscular disease, and are ventilator-dependent. You have and require two ventilators - one for use in bed, and another one attached to your wheelchair for mobility. Providing only a single ventilator would entail moving the ventilator and associated equipment between chair and bed at least twice daily, which would interrupt ventilatory support, posing a risk to you, and would not be practical. The purposes of the two ventilators are different (one for sleep and the other for mobility) and therefore do not represent duplication or "backup."  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 ventilator have been met. Therefore, we decided that the Plan has to pre-approve a home ventilator.   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Pembrolizumab for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the test showed the cancer is changing.  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 drug. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee has progression of disease at multiple sites, and possible immune-related nephritis on Pembrolizumab. Continuation of pembrolizumab in either of these circumstances would not be reasonable or medically necessary or safe and effective 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Pembrolizumab for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the resin-based composite - three surfaces, anterior (D2332), periodontal scaling and root planing - four or more teeth per quadrant (D4341), and periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided March 16, 2021.  You asked the Plan to provide additional payment for the resin-based composite and periodontal scaling and root planing. You say that your provider keeps giving different information and you don't feel you should be responsible for a consultation fee for each visit. The Plan denied your request. The Plan says the services have processed correctly.  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 resin-based composite and periodontal scaling and root planing with 20% coinsurance.   We looked at the file and Medicare rules. The Plan provided documentation showing that you were charged a total of $106.32 ($531.75 allowed amount x 20% coinsurance = 106.35). This means that you have been asked to pay less than or equal to the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide additional payment for the resin-based composite - three surfaces, anterior (D2332), periodontal scaling and root planing - four or more teeth per quadrant (D4341), and periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided March 16, 2021.