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

We decided that the Plan does not have to pre-approve femtosecond laser cataract surgery on the anterior eye segment.
You asked the Plan to pre-approve laser cataract surgical services. You say that this specific cataract surgery is medically necessary due to your other medical conditions. The Plan denied your request. The Plan says this procedure is considered experimental/investigational at this time.
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 laser cataract surgical services. 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 diagnosis of bilateral age-related nuclear cataracts. In this case, the documentation does not support that femtosecond laser cataract surgery on the anterior eye segment is medically reasonable and necessary for the enrollee in this case. This procedure is not an accepted standard of care at the present time due to a relatively higher incidence of adverse outcomes.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laser cataract surgical services have not been met. Therefore, we decided that the Plan does not have to pre-approve femtosecond laser cataract surgery on the anterior eye segment.
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 skilled nursing facility
services are medically necessary. The Plan denied your request. The Plan says coverage criteria is not 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 records show that
the enrollee's needs are primarily custodial at this time. The enrollee's 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 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 Contour home glucose test device.
You asked the Plan to pre-approve a Contour home glucose test device. You say that this is necessary for you.
The Plan denied your request. The Plan says that the non-preferred product is not covered.
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must
document in the beneficiary's medical record the reason why the specific brand or mode of delivery is
necessary to avoid an adverse medical outcome.
We looked at the file and Medicare rules. The file does not include any documentation from your physician
documenting why you require this specific brand of blood glucose meter. Without this, medical necessity
cannot be established. Therefore, we decided that the Plan does not have to pre-approve a Contour home
glucose test device.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a repeat Zilretta injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says that repeat therapy does not meet Medicare guidelines.
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 injection. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found the Food and Drug Administration (FDA)-approved label does not preclude the repeat use of Zilretta.
Additional dosing of Triamcinolone acetonide has been shown to result in a similar magnitude and duration of
clinical benefit as the first injection, and has been shown to be well-tolerated. Repeat administration has not
been associated with unexpected adverse effects, post-injection flares, or radiographic evidence of deleterious
effects on cartilage or other elements of joint structure.
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 injection have been met. Therefore, we decided that the Plan has to pre-
approve a repeat Zilretta injection.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says medical studies have not proven that this device is helpful for treatment of the
health problem.
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 to show safety and efficacy.
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (root canal) (D3320) provided on July 28, 2021.

You asked the Plan to pay for the root canal. You say that this service was medically necessary and should be covered. The Plan denied your request. The Plan says root canals (endodontic 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 pay for the endodontic therapy (root canal) (D3320) provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Contour One Touch Blood glucose test strips (CPT
code A4253).

You asked the Plan to pre-approve the strips. You say that you cannot use the products because the new
software makes it impossible to read any of your blood sugar values. The Plan denied your request. The Plan
says the request as not covered benefit as Abbott Diabetes Care (ADC) test strips are the sole preferred
products that are covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the strips have not been met. Contour brand test strips is a non-preferred product and not a covered
benefit. Abbott Diabetes Care (ADC) test strips are the sole preferred products that are covered. Therefore, we
cannot authorize the request for the non-preferred product at this time. Therefore, we decided that the Plan does
not have to pre-approve the Contour One Touch Blood glucose test strips (CPT code A4253).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on August 13, 2021.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says supplemental
eyewear must be obtained from a provider in the Plan's vision vendor 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. The Plan
covers these services when obtained from a provider in the Plan's vision vendor network.
We looked at the file and the Plan's rules. The file shows that the eyeglasses were not obtained from a provider
in the Plans vision vendor network.
Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met.
Therefore, we decided that the Plan does not have to pay for eyeglasses provided on August 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are
medically necessary. The Plan denied your request. The Plan says that the records received show that your
condition has improved, and you are no longer a threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is
not expected you will improve in a reasonable period of time as you are not showing any dangerousness to self
or others, auditory or visual hallucinations and are without aggressive behaviors while not showing any acute
threats of safety. You were cooperative and compliant with medication. It does not appear medically necessary
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of
care as you do not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal
behaviors. Our physician reviewer found that your condition does not meet criteria for inpatient psychiatric
hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions, a needle
injected into a patch of scar tissue with a solution to dissolve the tissue, completed in 1 day (CPT code 62264),
for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your
request. The Plan says the service is considered experimental and 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 the service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this is an experimental/ investigational procedure. Therefore, the request is considered not
medically reasonable or 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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve percutaneous lysis of epidural adhesions, a needle injected into a patch of scar tissue with a
solution to dissolve the tissue, completed in 1 day (CPT code 62264), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on September 20, 2021.
You asked the Plan to pay for a periodic oral evaluation and prophylaxis. You say that you disagree with the denial. You also say that you have had this dental coverage for over 14 years, and you have always been covered every six months. The Plan denied your request. The Plan says you have exhausted your annual maximum 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. The Plan provides an annual maximum benefit of $1,500 per year, for dental coverage.
We looked at the file and Medicare rules. The records show that you received dental services on February 22, 2021 and the Plan paid the allowed amount of $1,347.50. The records show you received dental services on March 1, 2021 and the Plan paid the allowed amount of $95. The records also show that you received dental services on March 15, 2021 and the Plan paid the allowed amount of $57.50. The Plan paid a total amount of $1,500 ($1,347.50 + $95 + $57.50 = $1,500). The EOC confirms you have an annual maximum benefit of $1,500 for dental services. Specifically, you have exhausted your annual maximum for dental coverage. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation and prophylaxis have not been met. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on September 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria.
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 you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
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 LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 There is no documentation provided indicating medical necessity for LTACH
services. 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 she 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states the
enrollee's rehabilitation and medical needs can be met with part-time skilled services in a lower level of care,
such as home with supervision and home health services. The Plan states home health services will need to be
approved by the enrollee's health plan and their rehabilitation needs can safely be received at a different setting,
for example, home with home health, in residential care, or home with close follow-up with the enrollee's
doctor.
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 the case file does not contain documentation
of required skilled nursing services. The enrollee will likely benefit from additional skilled therapy services.
The documentation is insufficient to demonstrate that the enrollee requires skilled therapy services on a daily
basis in a SNF.
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 SNF care.
Appeal type: SNF
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide services. You say that this care is necessary based on your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be covered. The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-approve home health aide services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on August 27, 2021.
You asked the Plan to pay for the urine PCR panel. 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. Review of the file shows that the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. The PCR testing is considered unproven and not medically necessary. This means that the PCR 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 urine polymerase chain reaction (PCR) panel provided on August 27, 2021.