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

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs adequate treatment of his diabetes, and to assess his ability to care at home. The Plan denied your request. The Plan says the enrollee does not require skilled services on a daily basis in an inpatient setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the enrollee is at supervision for dressing, independent for mobility, and supervision for transfers. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have enteral feedings, complex wound care or other SNF level skilled nursing need. His functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. He does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gel or gel-like pressure pad for mattress.
You asked the Plan to pre-approve a gel or gel-like pressure pad for mattress (E0185). You say that you cannot
walk and are incontinent. The Plan denied your request. The Plan says the clinical notes from January 14, 2020
indicate you are able to walk and are not incontinent.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Your medical record shows you are mobile. The medical record does
not show incontinence. Based on this information, we decided that Medicare rules for coverage of a gel or gellike
pressure pad for mattress (E0185) have not been met. Therefore, we decided that the Plan does not have to
pre-approve a gel or gel-like pressure pad for mattress.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services provided to the enrollee from January
2, 2019 to June 27, 2019 and billed under code S9328.
You asked the Plan to pay for code S9328. You say that these claims should be paid. The Plan denied your
request. The Plan says these claims were not coded correct per the Medicare billing guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, code S9328 is not valid for
Medicare billing purposes. Therefore, we decided that the Plan does not have to pay for home infusion services
provided to the enrollee from January 2, 2019 to June 27, 2019 and billed under code S9328.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient therapy services (97164) and waive the
coinsurance for outpatient therapy services (97112, 97140).
You asked the Plan to pay for outpatient therapy services (97164) and waive the coinsurance for outpatient
therapy services. You say that you were referred to this rehab provider by your Primary Care Physician. The
Plan denied your request. The Plan says the services that did pay were processed according to the appropriate
coinsurance. The services that didn't pay were not supported by medical records.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). 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. The rules also say that for Medicare to consider coverage and payment for any
item or service, the information submitted by the supplier or provider must corroborate the documentation in
the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Your
contract with the Plan clearly says that you must pay 50% coinsurance for outpatient therapy with an out of
network provider.
You have been asked to pay 50% coinsurance for outpatient therapy services with an out of network provider.
You have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The additional non-covered codes
(97112, 97140) are not payable as there was no documentation provided to support the billed codes (or the code
modifiers billed on the claim). Therefore, we decided that the Plan does not have to pay for outpatient therapy
services (97164) and waive the coinsurance for outpatient therapy services (97112, 97140).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto for the enrollee.
You asked the Plan to pre-approve Entresto. You say that Entresto is medically necessary. The Plan denied
your request. The Plan says Entresto is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entresto for the enrollee.
Benefits for Entresto 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 the services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 is currently undergoing treatment at an acute care hospital (ACH) for pancolitis, following recent treatment for a small bowel obstruction. The enrollee presented with a tracheotomy from her prior hospitalization. The enrollee is not currently on a ventilator. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) 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 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: Favorable

We decided that the Plan has to pay for hospital services provided on July 2, 2019 through July 30, 2019.
You asked the Plan to pay for the hospital services. You say that you would like reconsideration based on the
records submitted, The Plan denied your request. The Plan says that the claims are being submitted with
incorrect condition code to process and pay claim.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The documentation provided did not clarify why the condition code was was
inappropriate in this case or what services have been overturned. Without this information, we are unable to
substantiate the Plan's denial. Therefore, we decided that the Plan has to pay for hospital services provided on
July 2, 2019 through July 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does not require daily skilled therapy services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the enrollee requires oversight of his medical conditions and medication management. He has cognitive impairment and would not be expected to be able to adjust medications or self-monitor his medical conditions. He requires either physical therapy or occupational therapy for mobility. However, based on the enrollee's current condition, the expectation of achieving gains that would impact the burden of care at discharge with skilled services is not expected. Daily skilled services are not medically necessary or reasonable. As a practical matter, the enrollee does not require the necessary services on 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
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 because of a leg length discrepancy you need shoe inserts. The Plan denied your request. The Plan says this item is not a covered benefit.
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. Records show that you do not 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sildenafil 20mg tablets.
You asked the Plan to pre-approve Sildenafil 20mg tablets. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan only has part B coverage. Therefore, the criteria for self-administered drug coverage has 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 drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Sildenafil 20mg tablets.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Botox injections.
You asked the Plan to pre-approve the Botox injections. You say that the injections are medically necessary for
the treatment of the member's condition. The Plan denied your request. The Plan says that this is an off-label
use and is not included as an approvable diagnosis code per Medicare.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Botox injections. Our reviewer says
that research indicates that Botox injections should be reserved for those who fail pelvic floor physical therapy,
which this member has. Our physician reviewer found the injections are a medically necessary and safe
treatment for this member.
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 Botox injections have been met. Therefore, we decided that the Plan has to
pre-approve Botox injections.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair, accessories, and power seat elevation system. You asked the Plan to pre-approve a Group 3 heavy duty power wheelchair, accessories, and power seat
elevation system. You say that because of a medical condition the enrollee's foot falls off of the foot plate laterally and the enrollee hears rattling. The Plan denied your request. The Plan says the documentation does not show that the current power wheelchair is not meeting the enrollee's needs and repairs can be made. 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 the enrollee has a 4 year old Group 2 heavy duty power wheelchair. This power wheelchair serves the same purpose as a Group 3 heavy duty power wheelchair, accessories, and power seat elevation system at issue. The enrollee's power wheelchair is still under reasonable useful lifetime. Power seat elevation systems are statutorily not covered. The record does not show medical necessity for a replacement power
wheelchair. Therefore, we decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair, accessories, and power seat elevation system.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee admitted to the acute inpatient setting on 2/24/2020 for the treatment of community-acquired pneumonia. The enrollee's prior level of function was Independent. On 02/27/2020, a CT scan of the head showed no acute intracranial disease process identified. Generalized atrophy appears unchanged. The enrollee's current level of function per physical therapy notes from 3/5/2020 was the enrollee being moderately independent to supervision for transfers, ambulating 300 feet with moderate independence with rolling walker, and able to climb 6 steps with supervision. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have complex wound care or other SNF level skilled nursing need. This enrollee's functional status does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on 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 admission to a skilled nursing facility (SNF) have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98940) and an office consultation (99243) with provider, DC.You asked the Plan to pre-approve these services. You say that you need to continue chiropractic care as you recover from your injury.The Plan denied your request. The Plan says the documentation provided does not demonstrate subluxation of the spine by x-ray or physical exam.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 you do not meet criteria for coverage of chiropractic manipulative treatment. Our physician reviewer found the submitted imaging study of the lumbar spinereveals degenerative changes, disk space narrowing, and degenerative facet disease, but does not reveal evidence of a subluxation. An initial examination reveals decreased lumbar ranges of motion and positive orthopedictests. Neither the chart notes nor the examination reveals a subluxation of the spine per Medicare guidelines.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 chiropractic manipulative treatment (98940) and an office consultation (99243).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on September 18,
2019.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says
that the Plan requires utilization of network providers when possible and available, and requires authorization
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on September 18, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary.The Plan denied your request. The Plan says the enrollee must either have a history of osteoporotic fracture, or failure or contraindication to zoledronic acid first.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 Prolia. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of Age-related osteoporosis without current pathological fracture. The enrollee does not have a history of osteoporotic fracture. The Plan requires a trial of Zoledronic Acid first before they will approve the requested drug, Prolia. The enrollee in this case, has not tried and failed the required drug. The documentation does not support that Zoledronic acid 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 Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia.