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

We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT code(s): 64493 and 64494), for the enrollee.  
 
You asked the Plan to pre-approve the services. You say that significant clinical literature supports the safety 
and efficiency of this procedure which is medically indicated and appropriate for this enrollee. You state given 
the enrollee's medical history and treatment options you believe that, this is the best clinical option for this 
enrollee. The Plan denied your request. The Plan says there is no documentation that radiofrequency ablation is 
not medically appropriate for the enrollee, especially since the enrollee has had relief from it in the recent past. 
 
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 services. Our physician reviewer 
found a maximum of two facet levels may be tested. The notes show that enrollee does not need more testing. 
The enrollee has already received facet nerve test injections and a long acting radiofrequency ablation (RFA) 
treatment in the past. Diagnostic injections or MBB at the same level as the previously successful RFA 
procedure is not considered medically reasonable or necessary. Based on the policy, additional facet diagnostic 
injection sessions are not medically necessary and cannot be approved.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT 
code(s): 64493 and 64494), 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 you would like reconsideration because the IRF services are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria for the IRF services.
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 there are no complex nursing or rehabilitation needs.
There is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that it is hard to walk so you need the stockings to help with that, and it should be covered. The Plan denied your request. The Plan says it is a non covered item.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. It is also not covered per your Evidence of Coverage. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for office visits.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the requested provider is out-of-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 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 a referral out-of-network for office visits.
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 inpatient rehabilitation is needed for further 
recovery. The Plan denied your request. The Plan says under Medicare, your request is not medically 
necessary. 
 
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 that you do not require the intensity of services provided at an IRF.  
Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Your care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that you need a CGM. The
Plan denied your request. The Plan says medical records were not provided for review.
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 does not indicate that you use insulin with at least
three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing
results, or have had an in-person visit with their treating physician to assesses adherence to your CGM regimen
and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of a
therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have
to provide a therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve primary care services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve primary care services. You say that this doctor is familiar with your background and is sensitive to your needs. 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 primary care provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve primary care services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services (99213, G0127, 11720) provided on February 6, 2021.
You asked the Plan to pay for the podiatry services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for podiatry services (99213, G0127, 11720) provided on February 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion device.
You asked the Plan to pre-approve a continuous passive motion device. You say that a continuous passive motion device is required for use after shoulder surgery. The Plan denied your request. The Plan says this device is not covered by Medicare for use other than stretching after knee surgery.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion device for use after shoulder surgery.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for home-delivered meals. 
 
You asked the Plan to pre-approve home-delivered meals. You say that you never learned how to cook. You 
also say that you want this to be covered. The Plan denied your request. The Plan says home-delivered meals 
are not covered. The Plan says that 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home-delivered meals have not been met. Specifically, home-delivered meals are not covered by 
Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve coverage for home-
delivered meals.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on October 1, 2020, through October 15, 2020.
You asked the Plan to pay for SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says services were provided for 14 days as the discharge day or death is not counted, however the claim submitted and billed with 15 days.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Specifically, the record indicates that services were rendered for 14 days. The day of discharge or day of death is not counted as a billable day. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on October 1, 2020, through October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower overdenture (D5865) and 2 precision attachments (D5862).
You asked the Plan to pre-approve the dental services. You say that you needed these services for health reasons. The Plan denied your request. The Plan says complete lower overdenture is not listed as a covered service. The Plan says that precision attachments are not listed as covered services either.
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 overdenture and precision attachments are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete lower overdenture (D5865) and 2 precision attachments (D5862).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral diagnostic facet joint injections.
You asked the Plan to pre-approve bilateral diagnostic facet joint injections. You say that this request is medically necessary. The Plan denied your request. The Plan says the coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that the requested procedure requires two (2) medically reasonable and necessary diagnostic facet joint procedures with each one providing a consistent minimum of 80% relief of primary (index) pain. We looked at the file and Medicare rules. In this case, the record states that the second diagnostic facet joint injection did not provide at least 80% relief of primary pain.s Based on this information, we decided that Medicare rules for coverage of bilateral diagnostic facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral diagnostic facet joint injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the services. You say that the enrollee requires maximum assistance with daily activities. The Plan denied your request. The Plan says there are no noted daily skilled nursing or therapy needs.
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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there are no required skilled nursing services identified. At this time, it is not medically reasonable and necessary to provide skilled therapy services on a "daily basis" in a skilled nursing facility as an inpatient. The documentation does not support that the enrollee is ready for daily skilled therapy services. As a practical matter, the necessary services are not required on an inpatient basis in the skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for future computed tomography (CT) scans 
 
You asked the Plan to waive the copayments for future CT scans. You say that you changed insurance so that 
these services would be covered.  You said that no one told you about the copayment. The Plan denied your 
request. The Plan says enrollees are required to pay a copayment for CT scans. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for diagnostic radiology services (including CT scans).  
 
You have been asked to pay a $250 copayment for future CT scans. CT scans fall within the diagnostic 
radiology services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for future computed 
tomography (CT) scans
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your
request. The Plan says very little clinical information was received about the illness.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
We looked at the file and the Medicare rules. Despite multiple attempts by the plan, medical records were not
received. It cannot be determined if the scooter is appropriate and medically necessary for you. Based on this
information, we decided that Medicare rules for coverage of the scooter have not been met. Therefore, we
decided that the Plan does not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
You asked the Plan to preapprove the CGM. You say that the CGM is necessary. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria.
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 or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility.
You asked the Plan to pre-approve the admission. You say that this is not 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 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 services are not medically reasonable or necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF as your needs are current being met in the inpatient rehabilitation facility (IRF). You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. You are making gains in the IRF and his medical and functional needs are currently being met in the IRF facility therefore a transfer to a SNF 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.
You asked the Plan to pre-approve an epidural steroid injection. 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 follows Medicare rules. Medicare rules say that lumbar epidural steroid injections are covered when specific criteria is 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 an epidural steroid injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record provided is insufficient to establish that no contraindications exist to performing the requested procedure. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 an epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.