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 you need help to walk and regain strength. The Plan denied your request. The Plan says the requested IRF services do 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 based on the documentation provided, you do not require the intensity of services provided at an IRF.  Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met 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 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 admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with dementia, COVID-19 infection and a urinary tract infection. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. His lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy. By the dates in question, the beneficiary was at minimal assist level with functional mobility including gait to 200 feet. The enrollee required varying assist with activities of daily living. 

There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee 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 admission to a SNF 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete denture - mandibular (D5120).  

You asked the Plan to pre-approve a complete upper and lower denture. You say that you would like the plan to cover dentures. The Plan denied your request. The Plan says this service is not covered under your 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, 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 complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: Imaging
Decision: Partially Favorable

 We decided that the Plan has to pre-approve a CT scan of the chest. We decided that the Plan does not have to pre-approve a CT scan of the abdomen.   You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan says that the services are not medically necessary.  We decided that the Plan has to pre-approve a CT scan of the chest.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 these services.  Our reviewer says that the chest CT is medically necessary and the abdomen CT is not medically necessary. Our physician reviewer found the enrollee had a chest x-ray on November 10, 2021 that indicates unchanged eventration of the right hemidiaphragm and a patchy area of increased density at the right base, possibly atelectasis or pneumonia. This is unchanged since 2013 and eventration of the right hemidiaphragm is a common finding. The presence of an infiltrate at the right lung base is of some concern in a smoker. The best option is a CT of the chest with contrast to exclude a mass at the right base. The adrenal glands and the dome of the liver are included in the field of view in CT scans of the chest, which is sufficient to rule out a subdiaphragmatic cause of the eventration.  Thus, CT of the chest is reasonable but CT of the abdomen is not yet 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 the CT scan of the chest have been met. Therefore, we decided that the Plan has to pre-approve a CT scan of the chest.   We also decided that the Plan does not have to pre-approve a CT scan of the abdomen.  We looked at this physician's review, the file, and Medicare rules. The physician states that the CT scan of abdomen is not medically necessary. Based on this information, we decided that Medicare rules for coverage of the CT scan of the abdomen have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the abdomen.  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: Step-Therapy
Decision: Favorable

 We decided that the Plan has to pre-approve Ocrevus (Ocrelizumab).  You asked the Plan to pre-approve the Ocrevus (Ocrelizumab). You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says that the member does not meet step therapy exception criteria for coverage of this drug.  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 the Ocrevus (Ocrelizumab). Our reviewer says that the member meets step therapy exception criteria. Our physician reviewer found the enrollee's neurologist writes that Ocrevus is typically reserved for patients who are more advanced in their diagnosis and have failed to respond to other, less aggressive medications. It is the neurologist's professional opinion that, given the enrollee's age of diagnosis, she will see a more rapid progression in her neurologic symptoms, and does not have the time to try and fail other medications.  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 Ocrevus (Ocrelizumab) have been met. Therefore, we decided that the Plan has to pre-approve Ocrevus (Ocrelizumab).   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 expandable controller with harness and electronic connection.  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.  The Plan must follow Medicare rules. Medicare rules say that an expandable controller with harness and electronic connection are used to control multiple power options.  We looked at the file and Medicare rules. The requested expandable controller and harness with electronic connection are not needed to control the three approved power options. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a non-electric incentive spirometer.  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.  The Plan must follow Medicare rules. Medicare rules say that durable medical equipment (DME) must be able to withstand repeated use.  We looked at the file and Medicare rules. The item at issue is a non-electriconic incentive spirometer. This item cannot withstand repeated use. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-electric incentive spirometer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation per site (D7953).  You asked the Plan to pre-approve a bone replacement graft. You say that a bone graft is needed for socket preservation purposes. These procedures are necessary for dental implant placement. You also say that you would like the Plan to reconsider the procedure. The Plan denied your request. The Plan says the service requested is not listed as a covered benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation per site (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve diabetic testing supplies to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve diabetic testing supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be provided by a network provider.  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 diabetic testing supplies 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 continuous glucose monitor (CGM).  You asked the Plan to pre-approve these services. You say that you would like to monitor your glucose. The Plan denied your request. The Plan says the criteria for coverage are not met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses adherence to their CGM regimen and diabetes treatment plan.    We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three or more times per day or use an insulin pump. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a knee orthosis (L1852).  

You asked the Plan to pre-approve the knee orthosis. You say that the orthosis is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  

The Plan follows Medicare rules. Medicare rules say that a knee orthosis is covered only when there is recent injury, surgery, or documented knee instability.  

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 knee orthosis. Our reviewer says that the requested knee brace is not medically necessary. Our physician reviewer found records from the provided office visit do not document any recent surgery, injury, or knee instability on examination.  

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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1852).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #29.  You asked the Plan to pre-approve the crown. You say that you want to appeal this service because you are unable to eat and are losing weight. The Plan denied your request. The Plan says this service is not covered under your benefit plan.  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 crown (D2740) for tooth #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower denture (D5214).

You asked the Plan to pre-approve the dentures. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by your dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed.   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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a consultation, diagnostic service provided by a dentist or physician other than the requesting dentist or physician (D9310) and a tooth extraction (D7210) provided by an oral surgeon.  

You asked the Plan to pre-approve a consultation and a tooth extraction. You say that you have many health issues, and it is not worth going to a general dentist as an oral surgeon has more years of practice. You also say that you take antibiotics three times a day and the infection keeps coming back in the tooth. The Plan denied your request. The Plan says your Plan only provides coverage for dental services performed by a participating general dentist. 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 among those covered under this benefit. Specifically, services must be performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation, diagnostic service provided by a dentist or physician other than the requesting dentist or physician (D9310) and a tooth extraction (D7210) provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a tonsillectomy for the enrollee.  You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is no history of cancer and no concern for potential cancer.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found while suspected malignancy is a known indication for tonsillectomy, there are several common non-neoplastic indications as well, such as obstructive sleep apnea (OSA), sleep-disordered breathing, and recurrent tonsillar infections. However, the available documentation does not mention frequency of infections or other supporting data beyond noting that the enrollee had "frequent sore throats."  The enrollee was not found to have cervical adenopathy or exudate. There was no clinical suspicion of malignancy. Furthermore, although the history of snoring and mouth breathing was mentioned, there is no evidence of further work-up for these symptoms provided. There is also no formal diagnosis of obstructive sleep apnea. In summary, the requested tonsillectomy services do not meet criteria for being medically necessary and reasonable to treat 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a tonsillectomy for the enrollee.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the leg joint.  You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no documented trial of conservative care with physical therapy and medications.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the physical exam revealed soft tissue swelling, tenderness to palpation and restricted motion is worrisome for red flags including synovitis, joint effusion, etc. This constellation of physical findings is an indication for MRI without first trying physical therapy, since the physical findings are not consistent with the usual knee problems such as meniscal or ligamentous tears and the plain x-rays were negative.  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 MRI have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the leg joint.   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.