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

We decided that the Plan does not have to pre-approve a MyoPro orthotic. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested MyoPro device is not 
reasonable and necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of 
a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe 
for long term use. The device is therefore not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro orthotic.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy (90834) provided on February 9, 2021 to March 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the individual psychotherapy. You say that you called the provider services and they said that the enrollee has the benefit, as well as in and out of network benefits. The Plan denied your request. The Plan says non-emergent services with non-contracted providers require prior authorization before services being rendered. 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy (90834) provided on February 9, 2021 to March 16, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home delivery meals.
You asked the Plan to pre-approve home delivery meals. You say that per your health Plan benefits, you should have been provided the meals at time of discharge from the hospital on June 18, 2021 due to colon cancer surgery and you are still in need of the meals. The Plan denied your request. The Plan says your group coverage did not added the meals benefit until July 1, 2021.
The Plan contract did not provide coverage for the home delivery meals benefit until July 1, 2021. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home delivery meals have not been met. Therefore, we decided that the Plan does not have to pre-approve home delivery meals.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group three power wheelchair with multiple power options (K0861) and accessories (E2613, E2313, E2361, E0955, E2311, E1028, E1012, E2605, E1007, E2377). You asked the Plan to pre-approve a group three power wheelchair with multiple power options and accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage of the specific requested wheelchair have not been met.
The Plan must follow Medicare rules. Medicare rules say that a group three power wheelchair with multiple power options is covered if the beneficiary meets coverage criteria for a power tilt and recline seating system and the system is being used on the wheelchair, the beneficiary uses a ventilator which is mounted on the wheelchair, or the beneficiary requires a drive control interface other than a hand or chin-operated standard proportional joystick. A power seating system - tilt only, recline only, or combination tilt and recline - with or without power elevating legrests will be covered if the beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift, the beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed, or the power seating system is needed to manage increased tone or spasticity. If the power wheelchair base is not covered, then related accessories will be denied. We looked at the file and Medicare rules. The records show that the enrollee does not use a ventilator, require a drive control interface, or meet criteria for a power tilt and recline system. Specifically, in regard to the tilt and recline system, the enrollee does not utilize catherization or need the system to manage tone or spasticity. Although the records show that she has trouble with functional weight shifts, they do not show that she is at high risk for development of pressure ulcers. Based on this information, we decided that Medicare rules for coverage of a group three power wheelchair with multiple power options and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group three power wheelchair with multiple power options (K0861) and accessories (E2613, E2313, E2361, E0955, E2311, E1028, E1012, E2605, E1007, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunization provided on April 20, 2021.
You asked the Plan to pay for the shingles vaccine (90750). You say that this is a recommended vaccine and
was prescribed. The Plan denied your request. The Plan says this vaccine is not covered under your Medicare
Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine
(90750). The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the shingles
vaccine (90750). Therefore, we decided that the Plan does not have to pay for the immunization provided on
April 20, 2021.
Benefits for the shingles vaccine (90750) 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: Lab
Decision: Favorable

We decided that the Plan has to pay for the Caris CGP assay. 
 
You asked the Plan to pay for the Caris CGP assay. You say that you would like reconsideration because this 
denial is improper and contradicts the Plan's own policies. The Plan denied your request. The Plan says that 
coverage of CGP is limited to one test per specimen and precludes the use of any other molecular testing on the 
specimen. 
 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Caris CGP assay. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this testing is approved per National Comprehensive Cancer Network guidelines for non-small 
cell lung cancer. Broad panel molecular tests are recommended 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 Caris CGP assay have been met. Therefore, we decided that the Plan has to 
pay for the Caris CGP assay.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318), 60 mg/3 ml, in each knee. 
 
You asked the Plan to pre-approve Durolane in each knee. You say that the requested drug is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has not tried or cannot use 
Orthovisc and Monovisc.

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 Durolane in each knee. Our reviewer 
says that the requested for Durolane for both knees is not medically necessary. Our physician reviewer found 
the medical records provided do not indicate that the enrollee has tried and failed the required drugs, Monovisc 
and Orthovisc. The reviewer found that the medical records provided do not indicate that the plan's required 
drugs would likely be less effective and/or likely have adverse effects for the enrollee. therefore, the reviewer 
found that the step therapy criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane in each knee have not been met. Specifically, the file does not indicate 
that the enrollee has tried and failed the required drugs. Therefore, we decided that the Plan does not have to 
pre-approve Durolane (J7318), 60 mg/3 ml, in each knee.
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 enrollee will go backwards in their recovery 
without the time in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF 
care have not been met. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for confusion and upper gastrointestinal bleeding. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the documentation does support a need for physical and/or occupational therapy, there is no 
documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehabilitation care in order to recover enough to return home safely as soon as possible. The Plan denied your request. The Plan says the criteria for an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided in a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anorectal manometry pressure and sensation testing.
You asked the Plan to pre-approve the anorectal manometry testing. You say that it is felt this should be covered. The Plan denied your request. The Plan says the enrollee does not have a covered indication for this testing.
The Plan follows Medicare rules. Medicare rules say that anorectal manometry is indicated in the setting of constipation of uncertain etiology and/or incontinence of stool or urine. 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 anorectal manometry testing. Our reviewer says that the requested testing is not covered per the LCD and is not considered medically reasonable and necessary. Our physician reviewer found the enrollee has a history of recurrent right upper quadrant pain and gallbladder polyp. She also suffers from gastrointestinal reflux, adenomatous colon polyps and a family history of colon cancer. A digital rectal exam provided at the time of the last colonoscopy in June 2021 revealed no abnormalities. Anorectal manometry is indicated in the setting of constipation of uncertain etiology and/or incontinence of stool or urine. Neither is a condition supported by the available records. The requested testing is not shown to be medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anorectal manometry testing have not been met. Therefore, we decided that the Plan does not have to pre-approve anorectal manometry pressure and sensation testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a follow-up visit provided on December 18, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for a follow-up visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a follow-up visit provided on December 18, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 13, 2021 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
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. There is no referring provider. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 13, 2021 by a non-participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 18, 2020, 
to January 27, 2020. 

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
required no nursing services which would be considered skilled services by Medicare. 
 
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 pay for the skilled nursing services. 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 18, 2020, to January 27, 2020.
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 the 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 the SNF care. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have any
identifiable skilled nursing needs and does not require skilled therapy on a daily basis or at an inpatient level in
a SNF.
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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on February 6, 2020.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on February 6, 2020.