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

We decided that the Plan does not have to pre-approve the 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 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 the SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no qualifying diagnosis causing a mobility limitation for which a group 3
power wheelchair is medically needed.
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 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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the
documentation does not reveal that you use a ventilator attached to a wheelchair, is at high risk for
development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power
seating system to manage increased tone or spasticity therefore the request for power tilt and recline exceeds
your medical needs. The documentation indicates that you have Lewy Body Dementia. There is no detailed
cognitive evaluation indicating that you could safely operate this device. The documentation does not reveal
that you require other types of proportional input devices (e.g., mini-proportional or compact joysticks,
touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array,
etc.). You do not need to operate 3 or more powered seating actuators through the drive control, a separate
display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech
device or computer through the chair's drive control), or an attendant control. Your strength in the upper
extremities support that you can control any power options through their own individual switches.
Additionally, you do not have a qualifying diagnosis for a group 3 power wheelchair that is due to neurological
condition, a myopathy, or a congenital skeletal deformity. The request for Group 3 power wheelchair with
multiple power options 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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (CPT code 99213) to be performed by an
out-of-network provider.
You asked the Plan to pre-approve the out-of-network office visit. You say that the provider has been treating
you since February 2020. You state you do not drive and need a doctor closer to your home. The Plan denied
your request. The Plan says the services can be performed 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
the office visit (CPT code 99213) to be performed by an out-of-network provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 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 coverage criteria for 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 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 the SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 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 you do not meet Medicare coverage criteria for 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 you do 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services.
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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would provide no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.

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 appears to be improving and should only require short-term acute care services that can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Transfer to the LTACH will be considered not medically necessary at this time as it would not be clinically advantageous. Transfer to a lower level of care may be considered soon when treatment has completed.

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 SNF care.
You asked the Plan to pre-approve SNF care. You say that you cannot get to outpatient rehabilitation and home
health will not give you the therapy you need. You state you need inpatient skilled nursing to regain your
strength to walk again. The Plan denied your request. The Plan says your request does not show you have
skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. The Plan
states the services you require can safely be received at a different setting, for example, home with home
health, in residential care, or home with close follow-up with your doctor.
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 based on the medical records provided there is
no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment
of a skilled professional nurse are not required to safely and effectively provide medically necessary and
reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and
judgment of a qualified therapist are required to safely and effectively provide medically necessary and
reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient
basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear
appropriate in this case.
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: 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 needs more intensive rehabilitation care.
The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee is
unlikely to tolerate three hours of intensive therapy at least five days per week based on the documentation
provided. Skilled therapies may be provided in a less intensive 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) services.
You asked the Plan to pre-approve the CT scans. You say that the requested CT scans are necessary for
restaging. The Plan denied your request. The Plan says the requested CT scans are not medically reasonable
and necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
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 CT scans. Our reviewer says that
the criteria for coverage have not been met. Our physician reviewer found an 8-week interval scanning, with
the last scans being without disease, is not reasonable and necessary. Reimaging now is not appropriate. Repeat
imaging 3-6 months from the last scans is the standard.
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 CT scans have not been met. Therefore, we decided that the Plan does not
have to pre-approve computed tomography (CT) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional crown (D2740) and 2 core build up
(D2950).
You asked the Plan to pre-approve the dental services. You say that you lost your crown benefit for 2020
because your dentist billed for a crown that was not provided. You say that you want the 2020 benefit for 1
dental crown to carry over to 2021 because you are entitled to this benefit. The Plan denied your request. The
Plan says 1 crown is covered per year. The Plan says that core build up is not a covered service. The Plan also
says that there was no claim billed for any dental crowns for 2020.
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 crowns are listed as covered, the
frequency limit has been reached. The record shows that the Plan approved 1 of the 2 crowns that were
requested. Additionally, the requested core build up are not among those covered under this benefit. Therefore,
we decided that the Plan does not have to pre-approve an additional crown (D2740) and 2 core build up
(D2950)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Wharton's jelly injection.

You asked the Plan to pre-approve the requested services. You say that you have tried other treatments. The Plan denied your request. The Plan says there is little evidence that this is an appropriate procedure for knee pain.

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 you have chondromalacia patellae of the right knee. The requested treatment is not an approved therapy. It is not considered a cure for any medical condition. Therefore, the requested treatment is not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Wharton's jelly injection.
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 need inpatient rehabilitation services The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your needs can safely be met in 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 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 your 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 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lupron Depot.
You asked the Plan to pre-approve Lupron Depot. The Plan denied your request. The Plan says the enrollee has
not tried and failed Eligard or Firmagon
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 Lupron Depot. Our physician reviewer
found that the enrollee has prostate cancer. The Plan requires a trial of Eligard or Firmagon before they will
approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no
documentation provided indicating 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 Lupron Depot have not been met. Therefore, we decided that the Plan does not
have to pre-approve Lupron Depot.
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 these services are medically necessary for the
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bone Marrow Aspirate.
You asked the Plan to pre-approve Bone Marrow Aspirate. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says the requested procedure is not medically
necessary.
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 Bone Marrow Aspirate. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found Bone Marrow Aspirate remains experimental and more research is needed to show its
safety and efficacy when used as bone graft in spinal surgery.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Bone Marrow Aspirate have not been met. Therefore, we decided that the Plan
does not have to pre-approve Bone Marrow Aspirate