Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional therapy center attendance days.  You asked the Plan to pre-approve the additional therapy center attendance days. You say that the additional days are medically necessary. The Plan denied your request. The Plan says The additional days are not authorized by the IDT and therefore, non-covered.  The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status.   We looked at the file and Medicare rules. The interdisciplinary team has not authorized the additional days as they have determined the enrollee is progressing at home, and there is an increased risk of additional attendance due to the COVID-19 pandemic. Based on this information, we decided that Medicare rules for coverage of the additional therapy center attendance days have not been met. Therefore, we decided that the Plan does not have to pre-approve additional therapy center attendance days.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.  You asked the Plan to pre-approve a SNF admission. You say that you have an open wound that needs to be monitored, drained and changed frequently. You say that you are not able to walk without assistance. You say that you are very weak. You say that you struggle with daily functions. You also say that you need therapy so that you can get stronger and be discharged safely. The Plan denied your request. The Plan says the enrollee does not require skilled 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 a SNF admission. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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 a SNF admission have not been met. Specifically, the file does not indicate that the enrollee requires daily skilled services. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an ultra-light-weight manual wheelchair.  You asked the Plan to pre-approve an ultra-light-weight manual wheelchair. You say that the requested ultra-light-weight manual wheelchair is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested ultra-light-weight manual wheelchair.  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 an ultra-light-weight manual wheelchair. Our reviewer says that the enrollee does not meet criteria for the requested ultra-light-weight manual wheelchair. Our physician reviewer found the criteria for the ultra-light-weight manual wheelchair (K0005) has not been met per LCD - Manual Wheelchair Bases (L33788). The documentation does not reveal that the enrollee is a full-time manual wheelchair user. An 11/12/21 progress note physical exam states the enrollee has normal gait and station. There are no motor or sensory deficits. On the review of systems portion of the progress note the enrollee denies fatigue, weakness, chest pain, fatigue, muscle or joint pain, cough or shortness of breath. The documentation does not reveal that the enrollee requires individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, which cannot be accommodated by a K0001 through K0004 manual wheelchair. The documentation does not reveal an objective specialty evaluation that was performed by a licensed/certified medical professional (LCMP) without a financial relationship with the supplier who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the K0005 wheelchair and its special features.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ultra-light-weight manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultra-light-weight manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a replacement power wheelchair for the enrollee.  You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee currently has a power wheelchair that is less than five years old.  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 wheelchair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee meets Medicare criteria for a new power wheelchair in this case (as opposed to having the present power wheelchair repaired). Based on the records provided the cost of repairs to the present power wheelchair would be $4,735.63. The cost of a new power wheelchair is reported to be $18,127.79. Repair of the present power wheelchair is the most cost-efficient option 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement power wheelchair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator (E0466).  You asked the Plan to pre-approve a portable ventilator. You say that the item is medically necessary. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode that could be delivered by BiPAP is not covered.  The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as not reasonable and necessary.  We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Specifically, the requested device would be used in a BiPAP mode that could be provided with a BiPAP (E0471) device with AVAPS added to assure adequate tidal volumes. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466).
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 non-invasive ventilator therapy is required to reduce her risk of repeat hospitalization. The Plan denied your request. The Plan says a ventilator in a setting that could be delivered by BiPAP is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our physician reviewer found that the enrollee has COPD, severe obesity, and has had repeated hospitalizations for acute on chronic respiratory failure.    There is reportedly carbon dioxide retention on these admissions, although there is no ABG done while the patient is stable. There is no documentation of failure of BiPAP. Certain BiPAP devices can provide the AVAPS mode of support. Medicare does not cover a ventilator when used as BiPAP. Therefore, a home ventilator 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 a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Feraheme.  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 step therapy requirement is not met.  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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of other iron deficiency anemias. He has not tried and failed the Plan's required drugs, Infed and Venofer. The records do not show that the required drugs would be contraindicated or less effective; therefore, Feraheme 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme.
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 service is medically necessary. The Plan denied your request. The Plan says the service 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 are no complex nursing or rehabilitation needs. While you do have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  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, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 below knee alignable system addition (L5910) and lower extremity design socket addition (L5632).

You asked the Plan to pre-approve prosthetic additions. You say that the items are medically necessary. The Plan denied your request. The Plan says your current prosthesis included a below knee alignable system addition with no documentation of damage and that you have a Transtibial amputation, the brim design socket addition is for a Symes amputation.

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 a prosthetic with a below knee alignable system addition. The requested addition serves the same purpose as the one you currently have. Additionally, a Symes prosthetic addition is not medically necessary as you do not have that type of amputation. Therefore, we decided that the Plan does not have to pre-approve a below knee alignable system addition (L5910) and lower extremity design socket addition (L5632).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis (CPT code D7473).

You asked the Plan to pre-approve the dental services. You say that your dental provider requested for the procedure to be completed so the dentures may lay flush with your gums. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.

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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve removal of torus mandibularis (CPT code D7473).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 do not have documented skilled nursing or skilled therapy 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (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 service is medically necessary. The Plan denied your request. The Plan says the service 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 are no complex nursing or rehabilitation needs. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  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, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve the SNF admission. You say that the enrollee cannot go back to their facility due to the coronavirus. You also say that you believe that the enrollee needs professional help. The Plan denied your request. The Plan says the services are not medically necessary.

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 a skilled nursing facility (SNF) admission. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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 the SNF admission have not been met. Specifically, the file shows that the enrollee does not require skilled care. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. You say that the provider specializes in your cancer. The Plan denied your request. The Plan says services can be provided 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.

You asked the Plan to pre-approve the requested services. You say that conservative treatment has failed. The Plan denied your request. The Plan says there is a lack of evidence to support the device as safe and effective.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The file shows that a Vertiflex interspinous stabilization device was requested. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the requested device is experimental. More research is needed to show its safety and efficacy. Therefore, the requested services are 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 an interspinous stabilization device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra (J0517).

You asked the Plan to pre-approve Fasenra. You say that the drug is medically necessary. The Plan denied your request. The Plan says the drug 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 Fasenra. Our reviewer says that this drug is not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition and the Medicare approved drug compendia does not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fasenra have not been met. Therefore, we decided that the Plan does not have to pre-approve Fasenra (J0517).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Brukinsa capsule.

You asked the Plan to pre-approve Brukinsa. 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 Brukinsa capsule.

Benefits for Brukinsa may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.