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 this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You were admitted for a hypertensive urgency. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 an implant/abutment supported removable denture for
tooth 17, surgical placement of implant and attachment of abutments and attachments for tooth 20 and 28.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
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
implant/abutment supported removable denture for tooth 17, surgical placement of implant and attachment of
abutments and attachments for tooth 20 and 28.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve sacroiliac (SI) joint injection services (27096).
You asked the Plan to pre-approve SI joint injection services. You say that this procedure is medically necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that a second SI joint injection procedure will be considered if the initial pain relief is greater than or equal to 75% and the ability to perform previously maneuvers. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a SI joint injection. Our reviewer says that the requested procedure is medically reasonable and necessary. Our physician reviewer found in this case the record indicates that the enrollee underwent a diagnostic block on August 2, 2021 that gave greater than 75% relief. It has been more than one month since the first diagnostic injection. The elements of the coverage criteria are satisfied. The requested service is 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 a SI joint injection have been met. Therefore, we decided that the Plan has to pre-approve sacroiliac (SI) joint injection services (27096).
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an addition, endoskeletal system, above the knee or hip disarticulation, alignable system (L5920).
You asked the Plan to pre-approve an addition, endoskeletal system, above the knee alignable system. 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 follows Medicare rules. Medicare rules say that records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is 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 an addition, endoskeletal system, above the knee alignable system. Our reviewer says that the item is not medically necessary. Our physician reviewer found records do not document why the enrollee's present endoskeletal system, above knee, alignable system is inadequate to meet his needs with his new prosthetic parts which have been approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an addition, endoskeletal system, above the knee alignable system have not been met. Therefore, we decided that the Plan does not have to pre-approve an addition, endoskeletal system, above the knee or hip disarticulation, alignable system (L5920).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds criteria for LTACH. The Plan denied your request. The Plan says the requested LTACH care 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided indicating medical necessity for admission to an LTACH. 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 he 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K0004 manual wheelchair for the enrollee.

You asked the Plan to pre-approve a K0004 manual wheelchair. You say that a manual wheelchair is medically necessary. The Plan denied your request. The Plan says insufficient medical records have been provided to show the criteria required for the manual wheelchair requested are met.

The Plan must follow Medicare rules. Medicare has specific coverage criteria for a K0004 manual wheelchair. There were no medical records submitted with your appeal to support that the enrollee meets the criteria required for approval. Therefore, we decided that the Plan does not have to pre-approve a K0004 manual wheelchair for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery.

You asked the Plan to pre-approve Vertiflex superion device placement surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 superion device placement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not state that the enrollee is not indicated for operative intervention at no more than two levels. The record also indicates that the enrollee has osteopenia and scoliosis, but no further information is provided. The elements of the coverage criteria 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 Vertiflex superion device placement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nasal mask liners.
You asked the Plan to pre-approve nasal mask liners. You say that these liners protect your skin and protect from bacteria build up from your CPAP device. The Plan denied your request. The Plan says mask liners are not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve nasal mask liners.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested infusion pump.
You asked the Plan to pre-approve an infusion pump. You say that this pump is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for infusion pumps. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules. Our physician reviewer found based on the submitted information, this enrollee has not completed a preliminary trial of intraspinal opioid drug administration with a temporary intrathecal/epidural catheter as required by Medicare. In addition, the records state that the enrollee has experienced 90% pain relief with systemic opioids (Dilaudid). The enrollee also had an unsuccessful intrathecal pump trial on August 25, 2021. Medicare coverage criteria are not met. 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 pump have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming (CPT 62362 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Sleep Number Bed. 
 
You asked the Plan to pre-approve a Sleep Number Bed. You say that this bed is medically necessary. The Plan 
denied your request. The Plan says this type of bed is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  A Sleep Number Bed does not serve a purpose that is primarily medical in nature. This item 
is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Sleep Number Bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the tension sheath excision surgery to be provided by an 
OON provider. 
 
You asked the Plan to pre-approve the tension sheath excision surgery. You say that you would prefer to go to 
this facility because you had your last surgery there. The Plan denied your request. The Plan says the provider 
is out-of-network. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. The records provided for review do not show that the service at 
issue is urgent or emergent. 
 
Therefore, we decided that the Plan does not have to pre-approve the tension sheath excision surgery to be 
provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone graft at the time of implant placement and removable of impacted body.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 a bone graft at the time of implant placement and removable of impacted body.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on May 21, 2021.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you must use a doctor in our vision network.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by participating
vision provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on
May 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) mask to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) mask to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a toggle switch (K0108), cushioned headrest (E0955), manual swingaway (E1028), and a general use wheelchair seat cushion (E2601).
You asked the Plan to pre-approve a toggle switch, cushioned headrest, manual swingaway, and a general use wheelchair seat cushion. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are covered when specific criteria is met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a toggle switch, cushioned headrest, manual swingaway, and a general use wheelchair seat cushion. Our reviewer says that the items are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the coverage criteria detailed in the Local Coverage Determinations for the requested power wheelchair accessories. The records do not document necessity of the toggle switch as the power tilt feature comes with its switch. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a toggle switch, cushioned headrest, manual swingaway, and a general use wheelchair seat cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve a toggle switch (K0108), cushioned headrest (E0955), manual swingaway (E1028), and a general use wheelchair seat cushion (E2601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic socks.
You asked the Plan to pre-approve the socks. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve diabetic socks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a limited oral evaluation - problem focused (D0140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) to be rendered by an out-of-network (OON) oral surgeon.
You asked the Plan to pre-approve a limited oral exam and tooth extractions performed by an OON oral surgeon. You say that you are in pain and would like to see an oral surgeon. The Plan denied your request. The Plan says extractions are only performed when performed by a participating dentist.
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 limited oral exam and tooth extractions performed by an OON oral surgeon when the services are rendered by a participating provider. We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Based on this information, we decided that the Plan's rules for coverage of a limited oral exam and tooth extractions performed by an OON oral surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve a limited oral evaluation - problem focused (D0140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) to be rendered by an out-of-network (OON) oral surgeon.
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 would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the IRF services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. There is no documented need for a 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.