Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network providers.

You asked the Plan to provide coverage for an out of network provider. You say that you prefer to see the requested physician. The Plan denied your request. The Plan says this provider is not in 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can render this service. Therefore, we decided that the Plan does not have to provide coverage for the requested out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Prolia. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has diagnosis of disorder of bone and cartilage. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device (33289, C2624).

You asked the Plan to pre-approve the CardioMEMS device. You say that the monitoring device is medically
necessary. The Plan denied your request. The Plan says the service is considered investigational and non-covered.

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 CardioMEMS device. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the record indicates that the enrollee is unable to lay flat because of back pain. The
record indicates that the enrollee had worsened chronic kidney disease upon hospitalization but no recent
creatinine has been submitted to show resolution. The elements of the coverage criteria are not satisfied.

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 CardioMEMS device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a CardioMEMS device (33289, C2624).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 6 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 therapeutic continuous glucose
monitor (CGM) and monthly supplies.
You asked the Plan to pre-approve a FreeStyle Libre 2 therapeutic CGM and monthly supplies. You say that
the services are necessary. The Plan denied your request. The Plan says based on the documentation provided,
coverage criteria has not been met.
The Plan must follow Medicare rules. 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 indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
FreeStyle Libre 2 therapeutic CGM and monthly supplies have not been met. Therefore, we decided that the
Plan does not have to pre-approve a FreeStyle Libre 2 therapeutic continuous glucose monitor (CGM) and
monthly supplies.
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 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 does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program. There is not a reasonable expectation that this 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography and computed tomography (PETCT) scan of your body from your head to your thighs.

You asked the Plan to pre-approve a PETCT scan of your body from your head to your thighs. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that PET 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 a PETCT scan of your body from your head to your thighs. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record does not indicate that any other PET scan was performed. 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 PETCT scan of your body from your head to your thighs have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography and computed tomography (PETCT) scan of your body from your head to your thighs.

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 a pneumatic compression device (E0651, E0669) to be
provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the pneumatic compression device. You say that the items are medically
necessary. The Plan denied your request. The Plan says there are network providers available that can provide
the requested pneumatic compression device.
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 at issue in this appeal. We found no exception that would require the Plan
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a pneumatic
compression device (E0651, E0669) to be provided by an out-of-network (OON) provider
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve 16 additional fractions of radiation therapy (77385).
You asked the Plan to pre-approve the additional radiation therapy sessions. You say that the 16 additional fractions are medically necessary. The Plan denied your request. The Plan says that 28 fractions have been approved. The 16 additional fractions are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional radiation therapy sessions. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found treatment with more fractions is costlier, however, 44 fractions is considered acceptable by American Society for Radiation Oncology and National Comprehensive Care Network 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 the additional radiation therapy sessions have been met. Therefore, we decided that the Plan has to pre-approve 16 additional fractions of radiation therapy (77385).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cardiomems.

You asked the Plan to pre-approve Cardiomems. 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 Cardiomems. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee is unable to function, more consistent with class IV New York Heart Association (NYHA) heart failure, which is noted in the record. The elements of the coverage criteria are not satisfied. The requested service is not 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 Cardiomems have not been met. Therefore, we decided that the Plan does not have to pre-approve Cardiomems.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven (7) pontic - porcelain/ceramic teeth (D6245), a
bone graft (D6104), a bone replacement graft (D4263), guided tissue regeneration (D4266) and an implant
removal (D6100).
You asked the Plan to pre-approve pontic - porcelain/ceramic teeth, a bone graft, a bone replacement graft,
guided tissue regeneration and an implant removal.. You say that you have problems with your teeth and a lot
of bone loss, which causes you to choke when talking and eating. You also say that your denture is fractured in
multiple parts and you think it will be damaged soon. You are asking the Plan to review and reconsider
coverage. The Plan denied your request. The Plan says the services are 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
seven (7) pontic - porcelain/ceramic teeth (D6245), a bone graft (D6104), a bone replacement graft (D4263),
guided tissue regeneration (D4266) and an implant removal (D6100).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care.
You asked the Plan to pre-approve home health care. You say that the enrollee would benefit from skilled
nursing for disease management, post-operative recovery, medication review, assessment, and education. The
Plan denied your request. The Plan says the denial of authorization for home health care is correct.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve home health care. Our reviewer says
that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer
found the enrollee does not have documented skilled nursing needs. Home health skilled nursing visits are 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 home health care have not been met. Therefore, we decided that the Plan does
not have to pre-approve home health care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care visits.

You asked the Plan to pre-approve home health care. You say that the enrollee would benefit from skilled nursing for disease management, medication review, assessment, and education. The Plan denied your request. The Plan says the denial of authorization for home health care is correct, because the enrollee does not require the services of a skilled nurse.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve home health care. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer found the enrollee does not have documented skilled nursing needs or documented ongoing skilled physical therapy needs. The enrollee is functioning at a level commensurate with 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 home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement BiPAP device (E0470).
You asked the Plan to pre-approve a BiPAP device. You say that the requested item is a medical necessity for
you because your present model of BiPAP is subject to manufacturer recall. The Plan denied your request. The
Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the
reasonable useful lifetime of equipment in no case can be less than 5 years. Computation of the useful lifetime
is based on when the equipment is delivered to the enrollee, not the age of the equipment.
We looked at the file and Medicare rules. In this case, you are requesting a replacement BiPAP. The requested
replacement is for an item that has not outlasted its reasonable useful lifetime. The case record indicates that
the requested item is eligible for replacement by the manufacturer. Based on this information, we decided that
Medicare rules for coverage of a replacement BiPAP have not been met. Therefore, we decided that the Plan
does not have to pre-approve a replacement BiPAP device (E0470).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for one (1) additional physical therapy visit.
You asked the Plan to provide coverage for 1 additional physical therapy visit. You say that the enrollee needs 1 additional physical therapy visit to complete the evaluation. The Plan denied your request. The Plan says the requested additional visit does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 provide coverage for 1 additional physical therapy visit. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical 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 1 additional physical therapy visit have not been met. Therefore, we decided that the Plan does not have to provide coverage for one (1) additional physical therapy visit.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion surgery (63045, 22840, 63048, 22600).
You asked the Plan to pre-approve the spinal fusion surgery. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the spinal fusion surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of adequate conservative treatment attempts, to include physical therapy for neck pain. 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 spinal fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal fusion surgery (63045, 22840, 63048, 22600).