Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection, an expandable controller and a harness for expandable controller for the enrollee.
You asked the Plan to pre-approve these items. You say that the enrollee meets criteria for these items. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick.
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 these items. Our reviewer says that these items are not medically reasonable and necessary for the enrollee in this case. The patient does not need a special device for steering (such as a head switch or air puffs for control) on the wheelchair. She does not need to use a breathing machine (called a ventilator) which is attached to the wheelchair. She does not have a medical need for three (3) or more power seating features on the wheelchair. She is able to control the power wheel chair accessories with their own switches which are included in the approved wheelchair given her strength and functional history in the submitted documentation. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these items. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection, an expandable controller and a harness for expandable controller for the enrollee.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the other services. We decided that the Plan does not
have to waive the coinsurance for the outpatient surgery, the pathology service, or the anesthesia.
You asked the Plan to waive the coinsurance for the other services. You say that you were overcharged for this
surgery because it was a 'redo' from a prior surgery. The Plan says that you have been charged the correct cost
sharing amount.
We decided that the Plan has to waive the coinsurance for the other services.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. There were no medical records with the correct date of service or claim forms
submitted with the codes at issue to verify the billed services. Therefore, the plan has not shown that the
coinsurance amount you are being asked to pay is correct or justified by the health plan contract.
Plan says that you must pay a total of $675.04 for the other services. Based on the plan contract, however, you
cannot be asked to pay more than $0 for the other services. Therefore, we decided that Plan has to reduce the
copayment for the other services from $675.04 to $0.
We also decided that the Plan does not have to waive the coinsurance for the outpatient surgery, the
pathology service, or the anesthesia.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% for
the outpatient surgery, the pathology service, the anesthesia. See charge below.
Date of Service Service Allowed Amount Coinsurance Member Liability
August 14, 2019 Surgery services $204.24 20% $40.85
August 14, 2019 Pathology $40.56 20% $8.11
August 14, 2019 Surgery $542.21 20% $108.44
August 14, 2019 Surgery $542.21 20% $108.44
August 14, 2019 Anesthesia $99.45 20% $19.89
August 14, 2019 Anesthesia $99.45 20% $19.89
Total $305.62
Therefore, we decided that the Plan does not have to waive the coinsurance for the outpatient surgery, the
pathology service, or the anesthesia.
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 enrollee needs close monitoring of respiratory status and continued ventilator. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct, because the enrollee's care 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 current acute care hospital is able to provide all of the services the enrollee requires. Continued care at the current acute care hospital is appropriate until the enrollee is stable to transfer to a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you should not be left alone at home. The Plan denied your request. The Plan says your needs are considered custodial in nature.
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 from a nursing perspective, you have stable vital signs, and were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a minimal to moderate assist level with functional mobility. You require varying assist 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) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond January 31, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee had to stop receiving therapy for a short time due to an infection and needs more time to regain the progress lost during that time. The Plan denied your request. The Plan says the enrollee was able to progress with therapies despite infection and would not benefit from continued daily therapies.
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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 69 year female who fell and fractured her right hip on 01/02/2020 - she was admitted to an acute hospital and had surgical repair of the hip and then went to a skilled nursing facility on 01/07/2020 for physical therapy and rehabilitation. In the facility she developed an MRSA infection of the hip which was treated with intravenous antibiotics - reports indicate the infection cleared and the wound healed. As of 01/27/2020 she was ambulating with a walker 200 feet and requiring minimal assistance with activities of daily living. Last covered skilled day in the facility was 01/31/2020. Continued skilled nursing and therapy services in the facility are requested.
The medical records do not indicate a need for skilled nursing services or continued skilled therapy services. Care in the home or an assisted living facility with home health nursing and/or therapy services appears to be appropriate. 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond January 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveplacement of a Superion spinal spacer device.You asked the Planto pre-approvethe Superion spinal spacer. You say that this is not an experimentaldevice and should be considered medically necessary.The Plandenied your request. The Plansaysthere is not sufficient data to support coverage of this device.The Plan must follow Medicare rules. Medicare rulessay 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 Superion spinal spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device remains experimental. More research is needed.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 Superion spinal spacer have not been met.Therefore, we decided that the Plandoes not haveto pre-approveplacement of a Superion spinal spacer device.
Appeal type: Drugs
Decision: Unfavorable

e decided that the Plan does not have to pre-approveEuflexxa for the enrollee.You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically necessary.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 ithas 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 Euflexxa. Ourreviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of unilateral primary osteoarthritis of the left knee. The documentation does notsupport that the enrollee has tried and failed Orthovisc and Monovisc. The documentation does not support the Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the enrollee does not meet criteria for the requested Euflexxa.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided thatthe Plan does not have to pre-approveEuflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs vent weaning, active monitoring, and aggressive rehab therapy. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.
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 physician reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approvethe admission. You say that the enrollee's fixation failed, and her hip has collapsed.The Plandenied your request. The Plansaysthe enrollee's needs can be met at a lower level of care.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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not support that the enrollee needs daily PT and OT. There are no noted daily skilled complex nursing needs. While she may benefit from continuing PT and OT, the records do not support the need for daily therapy. Her needs are custodial in nature.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 Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecervical/thoracic interlaminar epidural for the enrollee.You asked the Plan topre-approvecervical/thoracic interlaminar epidural. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve cervical/thoracic interlaminar epidural. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic neck pain that radiates into the arms. The enrollee has the diagnosis of cervical spinal stenosis. The enrollee had trials of physical therapy and a home exercise program but only transient benefit. The enrollee does not meet criteria for the requested injections.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cervical/thoracic interlaminar epidural have not been met.Therefore, we decided that the Plandoes not have to pre-approvecervical/thoracic interlaminar epidural for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesacroiliac joint injection for the enrollee.You asked the Plan to pre-approvesacroiliac joint injection. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that injections are only covered for certain indications.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 sacroiliac joint injection. Our reviewer says that the documentation does not support that the requested injection services are medically reasonable or necessary. Our physician reviewer found the enrollee had a sacroiliac joint (SI) injection in August, 2018 with excellent response. The injection helped for several months (3-4months) and the enrollee was able to improve mobility, walking, sleeping, and activities of daily living. Sacroiliac (SI) joint injections would be considered medically reasonable and necessary for the diagnosis and/or treatment of chronic low back pain that is considered to be secondary to suspected sacroiliac joint dysfunction. Diagnostic and therapeutic injections of the SI joint would not likely be performed unless conservative therapy and noninvasive treatments (i.e., rest, physical therapy, nonsteroidal anti-inflammatory drugs, etc.) have failed. Since the previous injection, the enrollee has not had any conservative therapy or noninvasive treatments. Therefore, the enrollee does not meet criteria for the requested injection.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint injection have not been met.Therefore, we decided that the Plan does not have to pre-approvesacroiliac joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6533.You asked the Plan to pre-approvethe compression stockings. The Plan denied your request. The Plan says that these stockings are not covered by Medicare.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that you need a raised toilet seat because of your hip surgery. The Plan denied your request. The Plan says the requested item is not a covered service.
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 raised toilet seat.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansayscare can be provided in the current inpatient hospital.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 ACH for a left toe/foot infection. The enrollee has undergone amputation of his toe and is receiving a prolongedcourse of antibiotics. The enrollee is not intubated/ventilated. 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 timeno acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that a delay in care will have a detrimental effect on the enrollee's safety, and ability to recover to the fullest extent. The Plan denied your request. The Plan says it is uncertain the enrollee can participate in the intensity of services at an IRF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 physician reviewer found that the enrollee is at minimal assist for bed mobility, and transfer to a recliner using a rolling walker with minimal assist. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this or appear to be able to tolerate this therapy on an intensive rehabilitation facility therapy program level 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.