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

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that SNF care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The services needed can safely be received in a different 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 medically necessary. Our physician reviewer found that the enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is 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 skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network hip replacement surgery.
You asked the Plan to pre-approve out-of-network hip replacement surgery. You say that the requested hip replacement surgery with the out-of-network provider is medically necessary as the enrollee is receiving her cancer treatments at the out-of-network facility, her medical records are already there, and the out-of-network surgeon did her right hip replacement in the past. The Plan denied your request. The Plan says the requested out-of-network hip replacement surgery is not medically necessary and the enrollee can receive these services with an in-network provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 out-of-network hip replacement surgery. Our reviewer says that the requested out-of-network hip replacement surgery is not medically necessary. Our physician reviewer found the enrollee was being treated for osteonecrosis of left hip. She presented with increased left hip pain. She underwent a right total hip replacement on February 18, 2021. The x-rays of the left hip revealed sclerosis within the femoral head consistent with Ficat III osteonecrosis of left femoral head. However, detailed documentation is not evident regarding any significant findings/deficits that would require this enrollee to seek care outside of an in-network provider. There is evidence of orthopedic surgeons within the plan's network and documentation does not support that Standards of Care required for treatment would not be met using these providers. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, this enrollee is not currently receiving any active treatment and/or medical management for her condition that makes it medically necessary for this enrollee to continue care with the out-of-network orthopedic surgeon as requested. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of out-of-network hip replacement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve out-of-network hip replacement surgery.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GenVisc 850.
You asked the Plan to pre-approve GenVisc 850. 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.
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 GenVisc 850. Our reviewer says that the medication is not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Pan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of GenVisc 850 have not been met. Therefore, we decided that the Plan does not have to pre-approve GenVisc 850.
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 a transfer to a LTACH is medically necessary. The Plan denied your request. The Plan says the enrollee is not medically stable to transfer to another level of care. The Plan says that the enrollee does not meet the guidelines for long term acute care services.
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 the enrollee is tolerating a diet, there are no noted complex wounds, and sepsis has been resolved. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 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: 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 it is felt that LTACH would be the best
setting for the enrollee. The Plan denied your request. The Plan says the criteria for LTACH care are not 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 the enrollee was admitted for wound debridement. The enrollee continues to receive
intravenous antibiotics and wound care. The enrollee continues to receive acute care services and these have
not been denied at this time. The medical record does not indicate that the enrollee requires services that she is
not currently receiving, but that would be available at the LTACH facility. The elements of the coverage rules
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 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 the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of SNF care is 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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the member required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of October 28, 2021, the member did not require any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of October 28, 2021. The member did not have any parental medications, complex wound care or nutrition given via a feeding tube. The member received skilled care and improved; however, her function had plateaued by October 28, 2021 and she did not require any further inpatient skilled rehab services. The member's function was at or near her prior level of function and she could be discharged to a lower level of care for further services. As of October 28, 2021, the member required custodial 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 the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ofev.
You asked the Plan to pre-approve Ofev. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ofev.
Benefits for Ofev may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services to be provided by a chiropractor.
You asked the Plan to pre-approve the acupuncture services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve acupuncture services to be provided by a chiropractor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Kyphoplasty procedure (22514).
You asked the Plan to pre-approve the Kyphoplasty. You say that the procedure 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 this procedure is covered for a vertebral fracture less than 12 weeks old. 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 Kyphoplasty. Our reviewer says that the procedure is not medically necessary. Our physician reviewer found the records provided do not show that the fracture is less than 12 weeks old. 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 Kyphoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a Kyphoplasty procedure (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5225). 
 
You asked the Plan to pre-approve an upper partial denture. You say that you have submitted new x-rays and 
you are requesting the Plan to pay for the upper partial dentures. The Plan denied your request. The Plan says 
this service is not 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 an 
upper partial denture (D5225).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a routine transportation trip (A0120). 
 
You asked the Plan to pre-approve the transportation trip. You say that the additional mileage is needed for a 
medically necessary procedure. The Plan denied your request. The Plan says the requested trip exceeds the 
benefit provided. 
 
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 48 routine one-way trips per year, not to exceed 60 miles per trip. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for coverage of routine transportation have not been met. The trip requested is 81 miles. 
This exceeds the 60-mile benefit limit. Therefore, we decided that the Plan does not have to pre-approve a 
routine transportation trip (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oncology office visit (99214) to be provided by an 
out-of-network (OON) provider at the in-network rate. 
 
You asked the Plan to pre-approve the out-of-network office visit. You say that the service is medically 
necessary and should be covered at the in-network rate. The Plan denied your request. The Plan says there are 
network providers available that can provide this service. There is no grounds for an in-network exception. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the enrollee will pay a higher cost share if they use out-of-network providers, unless the service 
is emergent in nature or there are no network providers available. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to cover this service at the in-network rate. Therefore, we decided that the Plan does not have to pre-
approve an oncology office visit (99214) to be provided by an out-of-network (OON) provider at the in-
network rate.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no
documentation provided indicating medical necessity for admission to a 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.
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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve PuraPly XT (Q4197). 
 
You asked the Plan to pre-approve PuraPly XT. You say that the requested treatment is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that medical necessity rules for the requested item 
have not been met because the wound to be treated is smaller than required by Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers application of skin substitutes to 
ulcers or wounds with failed response when the criteria detailed in the Medicare rules section of this letter have 
been 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 PuraPly XT. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the coverage criteria, according to the medical progress note of July 29, 2021, have been met. 
Specifically, the enrollee's ulceration to be treated is noted to be 1.5 centimeters (cm) by 1 cm by 0.2 cm on 
July 29, 2021. This is greater than the required 1.0 square cm size that the ulceration must be prior to 
application of PuraPly. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PuraPly XT have been met. Therefore, we decided that the Plan has to pre-
approve PuraPly XT (Q4197).  
 
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: 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 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. 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 continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor 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 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 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553, K0554).