Persius/hicric huggingface dataset:
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 the SNF services. You say that SNF care is medically necessary. The Plan
denied your request. The Plan says the enrollee can safely receive the services needed in the hospital 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and used oxygen via nasal cannula. The enrollee received physical therapy, occupational therapy, and speech therapy in the hospital. By the dates in question, the enrollee was dependent with functional mobility. The enrollee required varying assist with activities of daily living. The enrollee tolerated mechanical soft diet and thin liquids. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14-Day Sensor (CPT code K0553). 
 
You asked the Plan to pre-approve the sensor. You say that the sensor is necessary. The Plan denied your 
request. The Plan says the Medicare rules have 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 you are not injecting insulin three 
or more times per day or are using a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. 
Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14-Day Sensor (CPT code 
K0553).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 
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 the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14-Day Sensor.
You asked the Plan to pre-approve the sensor. You say that this is to help you. The Plan denied your request. The Plan says the Medicare rules have 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 you are not adjusting your insulin doses based on your blood glucose readings. A CGM is covered for individuals who are intensely managing their diabetes, which requires changes in the dose of insulin. Based on this information, we decided that
Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14-Day Sensor
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the replacement interval for this is every five years.
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 device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found a replacement device is not covered. You are requesting a replacement device because of the recent recall on
certain devices. In the case of a manufacturer's recall, the manufacturer is responsible for replacing the device at no cost to the patient or the insurer. In this case there is no evidence that the device is non-functional and beyond repair. The device is less than 5 years 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve immunotherapy services to be provided by an out-ofnetwork
(OON) provider.
You asked the Plan to pre-approve immunotherapy services. You say that these services are medically
necessary. The Plan denied your request. The Plan says appropriate care is available in-network at this time.
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 if determined to be medically necessary.
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 immunotherapy services to be provided by an out-of-network
(OON) provider.
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 the SNF services. You say that that SNF care is medically necessary and the records provided support this need. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee's needs can be met at a lower level of care.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to ADLs with minimal supervision. Daily skilled services are not shown to be 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 the 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (CPT code G0483) provided to the enrollee on October 7, 2020.
You asked the Plan to pay for the drug test. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug test have not been met. CPT code G0483 remains not supported. The place of service on the CMS-1500 from line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on October 6, 2020, and received by the lab on October 7, 2020. Therefore, the billed code cannot be verified. Therefore, we decided that the Plan does not have to pay for the drug test (CPT code G0483) provided to the enrollee on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastroenterology to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve OON services. You say that the enrollee should see a more skilled
specialist. The Plan denied your request. The Plan says there are in-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 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,
both at the community and tertiary level, available who can provide the services at issue in this appeal. We
found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that
the Plan does not have to pre-approve gastroenterology 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 the MyoPro Motion G orthotic device (L8702) to be
provided by an OON provider.
You asked the Plan to pre-approve the orthotic device. You say that given that all the alternative treatments
have been tried and failed, the enrollee has been referred for myoelectric orthotic restoration. The Plan denied
your request. The Plan says enrollee's must receive their medical services from an in-network provider with the
exception being urgent or emergent services. This device has deluxe features that exceed the enrollee's need
and is not medically necessary.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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
the MyoPro Motion G orthotic device (L8702) to be provided by an OON provider.
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 the enrollee continues to receive intravenous antibiotics and other services as she is improving. 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. 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 continuation of SNF care from November 19, 2021, forward.
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.
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 at the time of admission, you required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of November 18, 2021, you did not require any skilled nursing or rehabilitation services on a daily basis. You were 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 (ADLs). You did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care as of November 18, 2021. You did not have any parental medications, complex wound care or nutrition given via a feeding tube. You received skilled care with minimal improvement. Your function had plateaued by November 18, 2021, and you did not require any further inpatient skilled rehabilitation services. Your function was at or near your new baseline level of function and you could be discharged to a lower level of care for further services. As of November 18, 2021, you required custodial services. The denial for further inpatient skilled care is upheld. 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 continuation of SNF care from November 19, 2021, forward.
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 enrollee's needs may also be met from part-time skilled services in long-term care. The Plan states home health and part-time skilled services would need to be approved by the enrollee's Health Plan.
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 enrollee has stabilized medically and has been receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF). The enrollee no longer requires daily skilled nursing and/or skilled therapy services. The enrollee could benefit from continued intermittent services at a lower level of care. Although the enrollee made good progress with therapy, their functional improvement has plateaued, there is no indication that transfer to a skilled nursing facility is required. The enrollee can continue to receive skilled rehabilitation services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an inpatient rehabilitation facility. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 enrollee's clinical condition meets the criteria for admission to an IRF, and these services are medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's care needs can be met in an alternate setting, such as the current LTACH facility.
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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services with regular physician evaluations. The enrollee's needs can be met in an alternate 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance (D4910).
You asked the Plan to pre-approve the dental service. You say that this service is necessary. The Plan denied
your request. The Plan says periodontal maintenance is not listed as a covered dental service.
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 periodontal maintenance
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to preapprove
periodontal maintenance (D4910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical procedure for isolation of tooth with rubber
dam (D3910) for teeth #s 28 and 30.
You asked the Plan to pre-approve the surgical procedure for isolation of tooth with rubber dam (D3910). You
say that you are worried about an infection and ending up in the hospital. You say that you are extremely
concerned about your health and want the services covered. The Plan denied your request. The Plan says core
buildup and endodontic therapy were approved. The Plan also says that the surgical procedure for isolation of
tooth with rubber dam (D3910) remains denied as a non-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 the
surgical procedure for isolation of tooth with rubber dam (D3910) for teeth #s 28 and 30.