Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  

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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation for extractions and dentures to be provided by an oral surgeon.

You asked the Plan to pre-approve the consultation, extractions, and dentures. You say that you feel that these services are medically necessary, which is what the doctor also says in their letter. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon 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. 

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 anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation for extractions and dentures to be provided by an oral surgeon.
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 device. You say that you were covered all through 2021. The Plan denied your request. The Plan says you do not meet the requirements.  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. The documentation does not indicate that you use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing result. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
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 inpatient rehabilitation is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the necessary services in an alternate setting.  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. Documentation does not support the need for physician supervision three times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute or complex rehab needs noted in the record. The enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least five days per week with a multidisciplinary approach to daily therapy. While the enrollee may benefit from physical and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and lower intensity setting, and an IRF is not medically 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 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ziextenzo (Q5120).  You asked the Plan to pre-approve Ziextenzo. You say that the requested drug is medically necessary for the enrollee's cancer treatment. The Plan denied your request. The Plan says the enrollee has not tried and failed at least 2 of the required drugs, Neulasta, Fulphila, or Udenyca.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Ziextenzo. Our reviewer says that the requested drug, Ziextenzo, is not medically necessary. Our physician reviewer found the provided documentation shows that the enrollee has tried and failed 1 of the required drugs, Udenyca (Pegfilgrastim-cbqv). The reviewer found that the file does not show that the enrollee has tried and failed at least 2 of the required drugs. The reviewer also found that either Neulasta (Pegfilgrastim) or Fulphila (Pegfilgrastim-jmdb) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the requested drug is not medically 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 Ziextenzo have not been met. Specifically, the file does not show that the enrollee trialed at least 2 of the required drugs. Therefore, we decided that the Plan does not have to pre-approve Ziextenzo (Q5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.

You asked the Plan to pay for foot orthotics. You say that the items are medically necessary. The Plan denied
your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot
orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for intermittent limb compression device (E0673).  You asked the Plan to pay for intermittent limb compression device. You say that the item is medically necessary The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for the prevention of deep vein thrombosis.  The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.  The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device (E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shoulder brace (L3960), provided on April 16, 2021.  You asked the Plan to pay for the shoulder brace. You say that the item is medically necessary. The Plan denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply code; nor did documentation indicate the provider discussed the need for the billed supply code.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The documentation submitted does not indicate medical necessity or that the provider discussed the need for the item. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the shoulder brace (L3960), provided on April 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 that based on the documentation provided, you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition.  Your 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra drops, 5%.  

You asked the Plan to pre-approve Xiidra. You say that the enrollee's condition has improved with this drug. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  

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 Xiidra drops, 5%.   

Benefits for Xiidra 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 and ground mileage (A0427-SH, A0425-SH) provided on March 14, 2021.  You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1 and ground mileage. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says Medicare will not pay for services rendered to incarcerated members unless certain criteria defined in 42 CFR 411.4 (b) is/are met.  The Plan must follow Medicare rules. Medicare rules say that providers and suppliers that render services or items to a prisoner or patient that is in custody should indicate this fact with the use of modifier QJ for claims.  We looked at the file and Medicare rules. Medicare rules say that providers and suppliers that render services or items to a prisoner or patient that is in custody should indicate this fact with the use of modifier QJ for claims. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 and ground mileage (A0427-SH, A0425-SH) provided on March 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).  

You asked the Plan to pre-approve a complete upper denture. You say that your current dentures do not fit correctly. 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 a complete upper denture once every 60 months.      

We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper denture was previously covered on September 25, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of a complete upper denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin D testing provided on July 12, 2021.

You asked the Plan to pay for the Vitamin D testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The Vitamin D testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Vitamin D testing provided on July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  January 26, 2021, through January 29, 2021.  You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says an inpatient admission was not medically necessary and that a 23-hour observation stay was safe and appropriate for this condition.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was hemodynamically stable without evidence of imminent danger to himself or others. Physical restraint was not required and there was no evidence of aggressive behavior. The enrollee has a history of chronic dementia being cared for at home with 24/7 care givers due to a history of dysfunction in daily living. This enrollee could have safely been treated in an outpatient setting and/or urgent care facility. An inpatient admission was not medically necessary, and a 23-hour observation stay was safe and appropriate for the enrollee's condition.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 26, 2021, through January 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex interspinous spacer procedure.

You asked the Plan to pre-approve Vertiflex interspinous spacer procedure. You say that you would like the plan to reconsider their denial because of your fear of falling and doing more damage. The Plan denied your request. The Plan says the requested services are 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 pre-approve Vertiflex interspinous spacer procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have a history of spinal stenosis. You have trialed acupuncture, chiropractor, exercise, Transcutaneous electrical nerve stimulation (TENS) unit, over the counter medications, and heat treatment with moderate relief. The Vertiflex device is experimental. More research is needed. Therefore, you do not meet criteria for the requested 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 Vertiflex interspinous spacer procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex interspinous spacer procedure.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gel-One (J7326).  You asked the Plan to pre-approve Gel-One. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the at least one of the preferred drugs, Durolane, Monovisc, or Synvisc-One.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Gel-One. Our reviewer says that the requested drug, Gel-One, is not medically necessary. Our physician reviewer found the provided documentation does not support that there has been trial and failure of the preferred drugs, Durolane, Monovisc, or Synvisc-One. The reviewer also found that the documentation does not support that Durolane, Monovisc, or Synvisc-One would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Gel-One have not been met. Specifically, the file does not show that the enrollee has tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the portable oxygen system (E0431) provided on September 20, 2021.  You asked the Plan to pay for the portable oxygen system. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the Medicare rule for payment for oxygen add-on code E0431 has not been met as it exceeded the monthly fee schedule amount per beneficiary.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code E0431 is not supported in the record. Specifically, the record indicates that CPT code E1392 was billed and paid for September 6, 2021. CPT code E0431 exceeds the monthly fee schedule amount for this beneficiary. Based on this information, we decided that Medicare rules for coverage of the portable oxygen system have not been met. Therefore, we decided that the Plan does not have to pay for the portable oxygen system (E0431) provided on September 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostatic arterial embolization (PAE).

You asked the Plan to pre-approve PAE surgery. You say that this is a safe and effective treatment with similar efficacy to traditional prostate surgery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because PAE surgery 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 PAE surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic benign prostate hyperplasia. Very limited studies have demonstrated possible short-term safety and efficacy. Recent guidelines do not recommend this procedure 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 PAE surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve prostatic arterial embolization (PAE).