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

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.  You asked the Plan to pre-approve the admission. You say that the enrollee has advanced Parkinson's disease and needs help with dressing, bathing, toileting, and eating. The Plan denied your request. The Plan says the enrollee's records do not show the enrollee has skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.  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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found that the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
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 Intracept Procedure. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental.
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 Intracept Procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental and more research is needed to show its 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 Intracept 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: Favorable

We decided that the Plan has to pre-approve a crown (D2752) and core buildup, including any pins when required (D2950) for tooth #19.
You asked the Plan to pre-approve the crown and core buildup. The Plan denied your request. The Plan says that the x-rays and clinical photos do not show destruction of at least 4 tooth surfaces or 2 cusps on tooth #19 due to decay or trauma. The Plan also says that tooth #19 may be restored with a resin or amalgam restoration.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown and core buildup when the services are medically necessary and reasonable. 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 crown and core buildup. Our reviewer says that the documentation provided meets the criteria for coverage for a core buildup (D2950) and crown restoration (D2752) for tooth #19. Our physician reviewer found a large restoration comprising 60% of the coronal tooth structure with recurrent caries and fracture lines is present in the tooth. Our reviewer found that the patient also has symptoms of sensitivity and pain with chewing pressure. Our physician reviewer also found that a core buildup and crown restoration is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown and core buildup have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2752) and core buildup, including any pins when required (D2950) for tooth #19.
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2752) and core build up (D2950) for teeth # 10, 18, and 30.
You asked the Plan to pre-approve the dental services. You say that the enrollee is in desperate need for these restorations. The Plan denied your request. The Plan says the requested services are not medically necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the requested crowns and core build up are not medically necessary. Our physician reviewer found the provided documentation indicates that teeth # 10, 28 and 30 have existing restorations that may be failing.
The documentation shows tooth # 10 has a two-surface restoration, tooth # 28 has a one-surface restoration, and tooth # 30 has a one-surface restoration. The reviewer found that the amount of tooth destruction on any of the involved teeth is not significant. Therefore, the reviewer found that the requested crowns and associated core build up are not reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the file does not indicate that the involved teeth have significant breakdown. Therefore, we decided that the Plan does not have to pre-approve crowns (D2752) and core build up (D2950) for teeth # 10, 18, and 30.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary level referral for a follow-up visit for total knee arthroplasty assessment.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says care is not required at a tertiary level facility.
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 referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not need the highly specialized level of care that a tertiary level referral would provide. Detailed documentation is not evident regarding the need for the office visit for the left total knee replacement to be performed at a tertiary provider's office. The documentation provided does not corroborate any significant abnormalities/co-morbidities that would preclude the requested procedure to be completed at the community setting. The published, large-scale, long-term peer-reviewed literature supports the requested follow up visit- 99213, CT scan- 73700, x-rays with leg lengths- 73562, 77073 as well as the left total knee replacement could be completed at the community level of care. There is no compelling rationale presented or
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the enrollee does not need the highly specialized level of care that a tertiary level referral would provide. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary level referral for a follow-up visit for total knee arthroplasty assessment.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cinacalcet (J0604), 1 tablet daily for 90 days.
You asked the Plan to pre-approve cinacalcet. You say that the requested drug is medically necessary for the enrollee's diagnosis. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
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 cinacalcet (J0604), 1 tablet daily for 90 days.
Benefits for cinacalcet 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 more home physical therapy (PT) visits (G0151).
You asked the Plan to pre-approve 9 more home PT visits. You say that the medical records reflect these services are medically necessary. The Plan denied your request. The Plan says the records do not support the need for a skilled physical therapist to make more home visits at this time.
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 9 more home PT visits. Our reviewer says that 9 more home physical therapy (PT) visits (G0151) are not medically reasonable and necessary. Our physician reviewer found the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the patient's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. Our reviewer found that the patient is at a high functional level. Our physician reviewer also found that the patient has had instruction in a home exercise program, and she does not require the ongoing professional skills of a therapist for her functional level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 9 more home PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 more home physical therapy (PT) visits (G0151).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy tablet 100mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not have a pharmacy benefit.
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 Ubrelvy tablet 100mg for the enrollee.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the enrollee needs strengthening to manage diabetes. The Plan denied your request. The Plan says that the enrollee does not meet Medicare criteria for SNF coverage under the Medicare Part A benefit.  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 the enrollee meets the Medicare criteria for SNF care. Our physician reviewer found the enrollee does have documented skilled nursing needs in the form of twice daily dressing care to coccyx wounds. Our reviewer found that the enrollee does have documented skilled therapy needs, as it is not yet clear that she has reached a plateau in function. Our physician reviewer also found that daily skilled services are required to establish a maintenance program or to prevent deterioration of 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.            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 ophthalmology visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you have seen several in-network ophthalmologists that have not been able to treat your condition. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network ophthalmologist.
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 ophthalmology visits 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 semi-electric hospital bed for the enrollee.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that enrollee's condition requires or has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for this 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 bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Sure Comfort lancets for the enrollee.  You asked the Plan to pre-approve the lancets. You say that this is medically necessary. The Plan denied your request. The Plan says this is a non-preferred supply.  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 lancets. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested item. The enrollee does not meet the criteria for coverage under Part B for a non-preferred diabetic supply bought at a pharmacy. There is not any medically reasonable indication to use this brand.  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 lancets have not been met. Therefore, we decided that the Plan does not have to pre-approve Sure Comfort lancets for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis tablet 5mg.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Eliquis is a self-administered drug.  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 Eliquis tablet 5mg.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vumerity caplet 231mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this was denied due to a benefit exclusion.
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 Vumerity caplet 231mg for the enrollee.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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 was admitted for coronary artery bypass grafting, left atrial appendage repair and repair of unruptured aortic aneurysm. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this considered an experimental/investigative 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.