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

We decided that the Plan does not have to pre-approve Neulasta Onpro.

You asked the Plan to pre-approve Neulasta Onpro. You say that the requested Neulasta Onpro is medically necessary. The Plan denied your request. The Plan says the requested Neulasta Onpro is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Neulasta Onpro. Our reviewer says that the requested Neulasta Onpro is not medically necessary. Our physician reviewer found the record indicates that the enrollee has metastatic bladder cancer and is being treated with cisplatin and gemcitabine as first line therapy. The record provided does not establish that the enrollee has a clinically significant high risk of febrile neutropenia. The elements of the coverage criteria are not satisfied. The requested service is not 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 Neulasta Onpro have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta Onpro.
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. The Plan denied your request. The Plan says your ongoing needs can be provided at a lower 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 IRF care. Our physician reviewer found that you were admitted to the acute care hospital after a fall, sustaining a left femur fracture. Functionally, you are at a maximal assist level for bed mobility and transfers, dependent for ambulation, minimal assist for upper body dressing, and dependent for lower body dressing. There are no nursing needs. At your current functional level, you do not require intensive therapies with a multidisciplinary approach to daily therapy.

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 a home ventilator.

You asked the Plan to pre-approve a home ventilator. 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 ventilators (E0465, E0466, and E0467) are covered when specific criteria are 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 a home ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation that a home ventilator was indicated. More recent neurology, pulmonary or sleep study records have not been submitted for review. Therefore, the documentation does not support that the requested home ventilator is currently medically necessary and 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 a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) to be provided by a participating provider.

You asked the Plan to pre-approve a maxillary partial denture. You say that you would like the Plan to reconsider coverage. The Plan denied your request. The Plan says the benefit for D5213 has already been exhausted.

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 a maxillary partial denture once every five years. 

We looked at the file and Medicare rules. Evidence was provided that shows D5213 was approved and paid for date of service November 6, 2018. Based on this information, we decided that the Plan's rules for coverage of a maxillary partial denture have already been met. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) to be provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 6, 2021.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the provider of services is not participating.

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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 6, 2021.
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 your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF or can be tolerated on an intensive level given therapy documentation of poor activity tolerance and deconditioning. 

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 endosteal implants (D6010), semi-precision attachments (D6192), cone beam imaging (D0367), implant/abutment supported removable denture (D6111) and a complete upper denture (D5110).

You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says the complete upper denture is a covered service, but this item may only be covered once every five years. you had a previous upper denture provided and covered in July of 2020, and therefore the benefit for this item is exhausted. The remaining services are not covered by your dental 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 or are requested in a frequency that exceeds what is covered by the benefit. The upper denture is a covered service; however, documentation shows that you received a complete upper denture on July 13, 2020, which was covered by the Plan at that time. This service may only be covered once every five plan years. Therefore, we decided that the Plan does not have to pre-approve endosteal implants (D6010), semi-precision attachments (D6192), cone beam imaging (D0367), implant/abutment supported removable denture (D6111) and a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).
You asked the Plan to pre-approve a partial upper denture. You say that you have never received an upper denture before. You say that your husband was the one that received the partial denture. You say that there was some sort of mix up. You also say that you need the requested denture. The Plan denied your request. The Plan says dentures are covered once per arch every 60 months. The Plan also says that the frequency limit 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 and partial upper denture is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a partial upper denture that you received on September 6, 2017. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve meals, per diem and nutritional counseling, dietitian visit, under the Healthy Pantry benefit.

You asked the Plan to pre-approve meals, per diem and nutritional counseling, dietitian visit under the Healthy Pantry benefit. The Plan denied your request. The Plan says you do not meet the criteria for coverage. The Plan was unable to verify that you have any of the health conditions that would qualify you for the benefit.

The Plan contract offers a supplemental Health Pantry benefit. The Plan benefit says you must provide supporting documentation from your physician identifying you as having a condition that can be made worse by not having or would benefit from having nutritional counseling and help obtaining appropriate pantry items.

We looked at the file and the Plan's rules. The file shows that the Plan was unable to verify that you have any of the health conditions that would qualify you for the Healthy Pantry benefit. Therefore, we decided that the Plan does not have to pre-approve meals, per diem and nutritional counseling, dietitian visit, under the
Healthy Pantry benefit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two pontics (D6245 x2), a retainer crown (D6740), and core buildups, including any pins when required (D2950) for tooth #'s 4 and 6.
You asked the Plan to pre-approve the pontics, retainer crown, and core buildups. The Plan denied your request. The Plan says pontic and retainer crown are not covered services. The Plan also says that core buildups are allowed one time every 60 months, and the enrollee has received this service on tooth #'s 4 and 6 less than 60 months ago.
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 pontic (D6245) and retainer crown (D6740) are not among those covered under this benefit. The contract says that the enrollee is limited to one of either codes D2950, D2952, or D2954 once per tooth per 60 months. The record shows that the enrollee received a core buildup, including any pins when required (D2950) on tooth #4 on February 17, 2021, and a prefabricated post and core (D2954) on tooth #6 on September 7, 2021 and the enrollee's core buildup (D2950) benefit for tooth #'s 4 and 6 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve two pontics (D6245 x2), a retainer crown (D6740), and core buildups, including any pins when required (D2950) for tooth #'s 4 and 6.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional physical therapy (PT) visits (97110).

You asked the Plan to pre-approve additional PT visits. You say that the additional PT visits requested are medically necessary. The Plan denied your request. The Plan says the additional PT visits requested do not meet criteria.

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 additional PT visits. 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 you have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the left leg prosthetic and accessories to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the left leg prosthetic and accessories. You say that the services are medically necessary. The Plan denied your request. The Plan says the 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. The records provided for review do not show that the services at issue are urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the left leg prosthetic and accessories 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 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 enrollee is with right hip fracture, status post-surgery with no complications, is stable and does not meet CMS coverage criteria for an IRF admission. With her current medical stability, and no medical complexity, there is no need for physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. She has no acute rehab nursing needs. At the current functional level, she does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. IRF admission is not medically necessary for an uncomplicated femur fracture based on lack of medical complexity and rehab nursing needs in addition high functional level for IRF intensity. Documentation does not support the necessity for admission to IRF. While the enrollee may benefit from continued physical therapy and occupational therapy, her rehabilitation needs can be safely met in an alternate and low intensity 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: 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 do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from continued physical therapy, speech therapy and occupational therapy, your rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility once you are medically stable and when you can participate in therapies. 

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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF 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 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 do not require the intensity of services provided at an IRF.

Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with 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: 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 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 at the time of discharge from the hospital. 

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of replaceable part of semi-precision or precision attachment, per attachment (D5867 x 2) to be provided out of network.

You asked the Plan to pre-approve the dental services. You say that you are not sure if you are going to need these services. You say that you would like them to be approved just in case. You also say that you are not able to chew anything. The Plan denied your request. The Plan says the requested provider is out of network. The Plan says that dental services are only covered when received by a participating provider. The Plan also says that there are in network providers available.

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 services to be received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve replacement of replaceable part of semi-precision or precision attachment, per attachment (D5867 x 2) to be provided out of network.