Persius/hicric huggingface dataset:
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 IRF services are medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the services they need in an alternate setting.

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 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient admission transfer to and out-of-network
facility.
You asked the Plan to pre-approve the inpatient admission transfer. You say that you would like
reconsideration because the member has been court ordered to the out-of-network facility. The Plan denied
your request. The Plan says the necessary care and services are available in the current hospital setting.
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
the inpatient admission transfer to and out-of-network facility.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional outpatient physical therapy (PT) visit.
You asked the Plan to pre-approve an additional PT visit. You say that you need additional physical therapy. You say that you are experiencing chronic fatigue, neck aches, and headaches. The Plan denied your request. The Plan says the enrollee is now able to exercise on his own and would be expected to improve with continuation of his home exercise program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 additional PT visit. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the provided documentation indicates that you have improved with therapy to the point of being able to manage your activities of daily living. The reviewer found that the provided documentation does not indicate why the previously approved physical therapy treatments have been inadequate to treat your condition. The reviewer found that you had additional therapy visits were approved previously to transition to a home exercise program. Therefore, the reviewer found that the additional visit 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 an additional PT visit have not been met. Specifically, the file shows that you have improved with therapy to the point of being able to manage your activities of daily living. Therefore, we decided that the Plan does not have to pre-approve an additional outpatient physical therapy (PT) visit
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve the portable ventilator. You say that you would like reconsideration because
the requested ventilator is medically necessary. The Plan denied your request. The Plan says the requested
portable ventilator is not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 portable ventilator. Our reviewer
says that the provided primary source documentation does not contain sufficient detailed information in the
medical record to justify the treatment selected. Our physician reviewer found 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 the portable ventilator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a portable ventilator
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper and lower denture.
You asked the Plan to pre-approve the complete upper and lower denture. You say that your first denture was stolen, and you need a new one. The Plan denied your request. The Plan says your maximum benefit has been reached.
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, you also have a maximum benefit of one complete or partial denture per arch every 60 months. The Plan paid for the complete upper and lower denture provided on April 28, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper and lower denture.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve the requested services. You say that the enrollee's pain affects their quality
of life. The Plan denied your request. The Plan says the clinical effectiveness has not been demonstrated in
peer-reviewed literature.
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 requested services. Our physician
reviewer found that the Intracept procedure is experimental. More research is needed to show its safety and
efficacy. Therefore, the requested procedure is not considered medically reasonable and 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration
because this is medically necessary to prevent future hospitalizations. The Plan denied your request. The Plan
says you do not meet Medicare coverage criteria for the requested compression stockings.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that
compression bandages and gradient compression wraps are covered only when they are used as dressings over
a qualifying wound.
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings
identified with code A6549
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sinus augmentation via a vertical approach (D7952),
retainer crowns - porcelain/ceramic (D6740), pontic - porcelain/ceramic (D6245), crown - porcelain/ceramic
(D2740), and core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve a sinus augmentation, retainer crowns, pontic, crown and core buildup. You
say that you would like the services covered. The Plan denied your request. The Plan says these services are not
covered under your benefits.
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 a
sinus augmentation via a vertical approach (D7952), retainer crowns - porcelain/ceramic (D6740), pontic -
porcelain/ceramic (D6245), crown - porcelain/ceramic (D2740), and core buildup, including any pins when
required (D2950)
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 requested admission to an IRF does not meet criteria.

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 you continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation doesn't support that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your functional status. You are near your prior level of function and can receive services 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the Medicare criteria for reasonable and necessary are not met as this device has not been shown to be safe and effective in long term studies and there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression. The Plan states the information submitted does not support that the enrollee meets the indications for this procedure as published by the manufacturer since imaging studies indicate mild stenosis.
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 interspinous spacer devices are experimental., More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the 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(s): 22869 and 22870), for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.
You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says the enrollee has not
tried and failed Orthovisc and Monovisc.
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 Hyalgan. Our physician reviewer found
that the enrollee has pain related to osteoarthritis of the left knee. She has failed conservative treatment. The
Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The enrollee has
not tried and failed the required drugs. There is no indication that the plan's required drugs would likely be less
effective 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have
to pre-approve Hyalgan
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a wheelchair from an OON provider. You say that the documentation provided supports the need for the custom medical equipment. The Plan denied your request. The Plan says the items being requested can be supplied by an in-network 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 a wheelchair to be provided by an out-of-network (OON) provider.
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 the IRF care. You say that the enrollee requires immediate inpatient
rehabilitation placement, as he is nearing discharge from the acute medical/surgical hospital. The Plan denied
your request. The Plan says this service is not medically necessary. The Plan also says that the enrollee's needs
can be met in an alternate, less intensive level of care.
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 the 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 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. Our reviewer
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and 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. Our physician reviewer also found that there is not a reasonable expectation that this enrollee 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 the 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 additional skilled nursing home health visits.
You asked the Plan to pre-approve the 9 additional visits. You say that you would like reconsideration because
the requested visits are medically necessary. The Plan denied your request. The Plan says the member does not
meet Medicare criteria for coverage of the additional visits.
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 the 9 additional visits. Our reviewer
says that the enrollee does not have documented skilled nursing needs. Our physician reviewer found the
requested, ongoing, home health skilled nursing services are not medically necessary or reasonable.
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 9 additional visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve 9 additional skilled nursing home health visits
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 you would like reconsideration because the SNF services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the SNF services.
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 daily skilled services are not shown
to be required to establish a maintenance program or to prevent deterioration of your 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee brace (L1851).
You asked the Plan to pre-approve the knee brace. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation submitted does not include
objective evidence of instability.
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 knee brace. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no evidence of left knee instability on a physical exam. There is no evidence of a recent
surgery or injury to the knee.
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 knee brace have not been met. Therefore, we decided that the Plan does not
have to pre-approve a knee brace (L1851)