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 you feel you need these services to help with safety
awareness, strengthening, endurance, and range of motion. The Plan denied your request. The Plan says the
requested IRF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found that 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. The
enrollee is stable and has no complex nursing or rehabilitation needs. The 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 patient has a need for physical and/or occupational therapy,
there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that there
is not a reasonable expectation that the 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. Specifically, there is no documentation of a need
for an intensive rehabilitation program. 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 a cone beam computed tomography (CT) capture (D0383).
You asked the Plan to pre-approve the dental service. You say that this service is medically necessary. The Plan denied your request. The Plan says cone beam CT capture is not listed as a covered 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 cone beam CT capture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture (D0383)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Interstim sacral nerve stimulation device trial (64561).

You asked the Plan to pre-approve an Interstim trial. You say that the enrollee has failed other treatments. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that patients with stress incontinence, urinary obstruction, and specific neurologic diseases which are associated with secondary manifestations of urinary urge incontinence, urgency-frequency syndrome, and urinary retention, are excluded from coverage of sacral nerve stimulation. 

We looked at the file and Medicare rules. The record shows that the enrollee has multiple sclerosis, a neurologic disease. Based on this information, we decided that Medicare rules for coverage of an Interstim trial have not been met. Therefore, we decided that the Plan does not have to pre-approve an Interstim sacral nerve stimulation device trial (64561).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the computed tomography (CT) abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions (74178).
You asked the Plan to pre-approve the CT scan. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the requested imaging is not reasonable or medically necessary and is not covered.
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 scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the current guidelines of the NCCN do not endorse upper tract imaging after five years in this clinical setting. If there is clinical suspicion of recurrence, for example, abnormal cytology, hematuria, the requested imaging would be considered. Therefore, the request 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the computed tomography (CT) abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions (74178).
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 SNF services. You say that you need physical and outpatient therapy. The Plan denied your request. The Plan says that your record does not show that you require daily skilled nursing or skilled therapy in a SNF 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 19, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 out of network physician services provided to the enrollee on August 19, 2021.
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 SNF services. The Plan denied your request. The Plan says you do not require inpatient therapy services or daily skilled nursing needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, your lungs were clear, and you were treated for chronic pain. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you received home care. You require some help with functional mobility with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda).
You asked the Plan to pre-approve Keytruda. You say that the enrollee has previously been on it and has not progressed. The Plan denied your request. The Plan says the medication is not being prescribed for a medically accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Keytruda. Our physician reviewer found that the enrollee has a diagnosis of urothelial carcinoma. The requested use of Keytruda is not FDA-approved for the enrollee's condition in combination with enfortumab (Padcev). The requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve pembrolizumab (Keytruda).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953).
You asked the Plan to pre-approve a bone replacement graft for ridge preservation. You say that the requested service is a necessity for your care. The Plan denied your request. The Plan says the requested service is not a 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 item or service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. You say that the SNF admission is medically necessary.
The Plan denied your request. The Plan says the enrollee does not have daily skilled nursing 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 SNF admission. Our reviewer says that
the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled
professional nurse. Though the enrollee has some identifiable skilled therapy needs, they do not have daily
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional
therapist. Therefore, the enrollee does not require daily skilled nursing and/or skilled therapy on 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 SNF admission have not been met. Specifically, the file does not show that the
enrollee requires daily skilled services. Therefore, we decided that the Plan does not have to pre-approve
skilled nursing facility (SNF) admission
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be received in a different 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
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 appears to be improving and should only require short-term additional acute care services at this time that can be successfully completed safely at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 13 hours of homemaker services per week.
You asked the Plan to pre-approve the additional 13 hours of homemaker services per week. You say that the enrollee requires at least 8 hours of homemaker services per day, 7 days a week, due to her physical and mental limitations. The Plan denied your request. The Plan says the enrollee was approved for 35 hours of homemaker services weekly or 5 hours daily, which should be sufficient to meet their needs.
The Plan also says that the enrollee does not have immediate short-term needs or any extenuating circumstances for which granting the additional 13 hours of homemaker services is warranted.
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 additional 13 hours of homemaker services per week. Our reviewer says that the additional 13 hours of homemaker services per week are not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee is medically stable without any recent hospitalizations or medical complications. The approved 35 homemaker hours weekly allows for appropriate support and care. Our reviewer found that the documentation does not support that the additional hours are needed to provide adequate support for the enrollee. Our physician reviewer also found that the enrollee is medically and functionally stable and does not have any additional skilled needs. 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 additional 13 hours of homemaker services per week have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 13 hours of homemaker services per week.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the OneTouch Verio Test Strips.
You asked the Plan to pre-approve the OneTouch Verio Test Strips. You say that this equipment is necessary over the Plan's preferred brand. The Plan denied your request. The Plan says there is no evidence the Plan's preferred test strips would not be sufficient.
The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. In this case, despite the Plan's efforts, no medical records were received regarding the medical necessity of the requested equipment. Based on this information, we decided that Medicare rules for coverage of the OneTouch Verio Test Strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the OneTouch Verio Test Strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you suffer from foot cramps. The Plan denied your request. The Plan says this item is not covered for your condition.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. The records do not show that you suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial dentures to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve dentures. You say that you prefer to go to this provider. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because this provider is out-
of-network with the Plan and there are in-network providers available who can provide the requested 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 items or services are not 
among those covered under this benefit when performed by an out-of-network provider. Therefore, we decided 
that the Plan does not have to pre-approve partial dentures to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve localized delivery of anti-microbial agents (D4381 x 8).
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says localized delivery of anti-microbial agents is not 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 localized delivery of anti-microbial agents are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve localized delivery of anti-microbial agents (D4381 x 8).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MPI is 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that the enrollee has an irregular heartbeat and underwent the requested service in October of 2020 with normal findings. The record does not indicate the presence of any new symptoms or findings. The criteria for coverage are not met and the MPI is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI).