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 care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for IRF care have 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 that the patient was admitted for sepsis and a urinary tract infection. Medical
problems are stable. There are no complex nursing or rehabilitation needs. The patient 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. In conclusion, there is not a reasonable
expectation that this patient 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been
met.
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 was admitted with endocarditis. The record indicates that the enrollee is
improving but still requires ongoing acute care services. The enrollee continues to receive acute care services,
and these have not been denied. The medical record does not indicate that the enrollee requires services that he
is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules
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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit (99204, 99203) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a specialist office visit. You say that you need to see this provider because this is the only doctor who specializes in your condition. The Plan denied your request. The Plan says the provider you requested is out-of-network. The Plan also says they have a special provider in-network who treats diseases in which a body attacks its own cells.

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. 

he 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 specialist office visit (99204, 99203) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5223) and immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5224).
You asked the Plan to pre-approve the immediate upper and lower partial dentures. You say that you need these special dentures approved. 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 an immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5223) and immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5224).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve back canes and hand rims for a wheelchair (K0108).
You asked the Plan to pre-approve the wheelchair features. You say that the items are medically necessary. The Plan denied your request. The Plan says these features are already included with the approved standard wheelchair and are not separately billable.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have already been approved for a manual wheelchair that includes these features. Therefore, we decided that the Plan does not have to pre-approve back canes and hand rims for a wheelchair (K0108).
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 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 the complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical
therapy and occupational therapy services but based on the medical records provided you do not require an
intensive inpatient rehabilitation therapy program. Medically necessary services can be provided in a different
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7210), bone grafting (D7953), dental implant (D6010), abutment supported crown (D6061), radiographic/surgical splint index (D6190), prefabricated abutment (D6056) and cone beam computed tomography (CT) capture (D0367).
You asked the Plan to pre-approve the dental services. You say that you had a crown fall off in the front of your mouth. The Plan denied your request. The Plan says the requested dental services are not covered services.
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 extraction, bone grafting,
implant related services, and cone beam CT are not among those covered under this benefit. Additionally, the Plan confirmed that the requested provider is out of network. While you can use out of network providers, they may charge you more for services. Therefore, we decided that the Plan does not have to pre-approve an extraction (D7210), bone grafting (D7953), dental implant (D6010), abutment supported crown (D6061), radiographic/surgical splint index (D6190), prefabricated abutment (D6056) and cone beam computed tomography (CT) capture (D0367).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF)
services.
You asked the Plan to pre-approve the continuation of SNF care. You say that the clinical information provided
supports the need for continued SNF care. The Plan denied your request. The Plan says the guidelines for
coverage have 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 the continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no
identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not
required on a daily basis. The enrollee does not require services on an inpatient basis, only in a SNF setting.
Services in the home with home health care or 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 the continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214), and a complete maxillary denture (D5110) to be provided by a participating provider.
You asked the Plan to pre-approve a mandibular partial denture and a complete maxillary denture. You say that you would like the Plan to approve and pay for this dental work. The Plan denied your request. The Plan says the requested dental services are not covered services.
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 mandibular partial denture (D5214), and a complete maxillary denture (D5110) to be provided by a participating 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 requested admission to an IRF 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 there is no need for physician supervision 3 times per week (at a minimum) for the
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the
current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to
daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of
therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no
documented acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy and
occupational therapy, the rehabilitation needs can be safely met in an alternate and lower 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: 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 services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the enrollee is no longer showing improvements in completing short term goals in a reasonable and predictable time frame.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not support that the enrollee in this case requires skilled therapy services on a daily basis in an inpatient skilled nursing facility setting. No daily required skilled nursing services are identified. 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 admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site
(D4266) and bone replacement graft for ridge preservation - per site (D7953).
You asked the Plan to pre-approve guided tissue regeneration and bone replacement graft. You say that you
would like these services covered as soon as possible. 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
guided tissue regeneration - resorbable barrier, per site (D4266) and bone replacement graft for ridge
preservation - per site (D7953).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genetic testing.  You asked the Plan to pre-approve the genetic testing. You say that the genetic testing is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that testing of individuals with no personal history (a previous or present diagnosis) of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer is not covered.  We looked at the file and Medicare rules. The records provided show no personal history of a covered indication. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Actemra (tocilizumab).  You asked the Plan to pre-approve Actemra. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.    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 Actemra. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has a diagnosis of Systemic sclerosis. The documentation does not support that the enrollee has tried and failed Remicade, Inflectra, Infliximab, or Simponi Aria. The documentation does not support that Remicade, Inflectra, Infliximab, or Simponi Aria would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Actemra have not been met. Therefore, we decided that the Plan does not have to pre-approve Actemra (tocilizumab).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve the Intracept procedure. The Plan denied your request. The Plan says the Intracept procedure does not meet the definition of reasonable and 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 the Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Intracept procedure is 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a telephone alert device (A9280).  You asked the Plan to pre-approve the telephone alert device. You say that the device is medically necessary. The Plan denied your request. The Plan says this device is not covered.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a telephone alert device (A9280).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Telmisartan-Hydrochlorothiazide tablet.
You asked the Plan to pre-approve Telmisartan-Hydrochlorothiazide tablet. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Telmisartan-Hydrochlorothiazide tablet.
Benefits for Telmisartan-Hydrochlorothiazide tablet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to receive acute inpatient services that have not been denied. The record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH. 

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.