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

We decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair (K0861).
You asked the Plan to pre-approve the Group 3 Power Wheelchair. You say that you would like
reconsideration because the Group 3 with multiple power seating and positioning options satisfies the member's
needs for alternate mechanical means of managing pressure reduction, improves access for
clothing/brief/catheter management, reduces the quantity and frequency of functional transfers to/from the
power wheelchair as well as provides safe, independent repositioning for managing chronic back pain. The
Plan denied your request. The Plan says the record does not show that the member has an indicated condition
for the Group 3 Power Wheelchair.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for
enrollees who have a mobility limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition,
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a
Group 3 Power Wheelchair (K0861).
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 SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on review of the available records, the enrollee does not meet the CMS coverage criteria for an admission to an SNF. He was medically stable. Had no daily skilled nursing needs. At his current level of function, he does not require daily skilled therapies in an inpatient setting. Admission 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 admission to a 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diltiazem extended-release (ER), for the enrollee.
You asked the Plan to pre-approve the medication. You say that the enrollee has been on this medication since August 31, 2020, and needs to stay on it. The Plan denied your request. The Plan says this medication is a self-administered drug and does not fall under Part B covered. The Plan state the enrollee does not have pharmacy benefits administered by the Plan.
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 Diltiazem extended-release (ER), for the enrollee.
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you need LTACH care. The Plan denied your request. The Plan says rules for LTACH care have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to an LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transfer bench for tub or toilet with or without commode opening (E0247).

You asked the Plan to pre-approve the transfer bench. You say that you disagree with this decision and request an appeal because this item is necessary for a medical reason. The Plan denied your request. The Plan says this item is a convenience item and is not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the transfer bench for tub or toilet with or without commode opening (E0247).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacral lateral nerve radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of radiofrequency ablation to the sacroiliac joint in the setting of sacroiliitis have not been demonstrated in the peer-reviewed literature.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure due to the wide variation in clinical efficacy reported in the literature. Therefore, the request is considered 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacral lateral nerve radiofrequency ablation for the enrollee.
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 the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says therapy can be safely received at a different setting, for example: outpatient therapy
in residential long-term care.
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 admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no
identifiable skilled nursing or 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 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 the admission 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve acupuncture services. You say that you have seen other providers before and have had negative or ineffective treatments. You say that you prefer to see this provider as you have had a great experience with the provider. The Plan denied your request. The Plan says this provider is not part of the Plan's preferred network, and there are in-network acupuncturists available.

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 services. Therefore, we decided that the Plan does not have to pre-approve acupuncture services to be provided by the requested out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional non-emergency routine transportation trips.

You asked the Plan to provide coverage for additional non-emergency routine transportation trips. You say that you need transportation to your medical appointments, and you do not have family or financial resources to assist you. The Plan denied your request. The Plan says you have exhausted the benefit for this year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional non-emergency routine transportation trips.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. 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 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. You say that the requested Synvisc-One is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc 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 Synvisc-One. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovsic first before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breast MRI.
You asked the Plan to pre-approve a breast MRI. You say that you were advised that at 70 years the Plan no longer provides the annual mammogram. The Plan denied your request. The Plan says expert review and testimony indicate MRI of the breast is not indicated but you may continue the annual screening mammography indefinitely.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve a breast MRI. Our reviewer says that the service is not medically necessary. Our physician reviewer found the patient met with genetic counseling and declined testing. Her lifetime risk of breast cancer was determined to be less than 20%. Family history is one of the factors used to determine lifetime risk. She does not meet coverage criteria for an annual MRI. The service is 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 a breast MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a breast MRI.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the vasectomy procedure (55250) provided April 16, 2021.

You asked the Plan to pay for the vasectomy procedure. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that elective sterilization services are not covered by Medicare. 

We looked at the file and Medicare rules. In this case, the procedure performed was elective sterilization. Based on this information, we decided that Medicare rules for coverage of the vasectomy procedure have not been met. Therefore, we decided that the Plan does not have to pay for the vasectomy procedure (55250) provided April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an allowance to cover the services for an emotional 
support dog. 
 
You asked the Plan to pre-approve an allowance to cover the services for an emotional support dog. You say 
that you need your dog for emotional support due to the pandemic. Also because of the pandemic, you have lost hours at work and cannot afford to buy everything your puppy needs. The Plan denied your request. The 
Plan says that dogs whose sole function is to provide comfort or emotional support do not qualify as service 
animals under the ADA. You do not qualify for this benefit because you do not have a service dog that is 
trained and is certified as an ADA approved service dog, as well as meet the medical diagnosis criteria for this 
benefit. The dog that you own is an emotional support animal, which does not qualify as a service animal under 
the ADA.  
 
The Plan contract offers a supplemental service dog support benefit.   
 
We looked at the file and the Plan's rules. The file shows that you do not qualify for this benefit because you 
do not have a service dog that is trained and is certified as an ADA approved service dog, as well as meet the 
medical diagnosis criteria for this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
allowance to cover the services for an emotional support dog.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neurosurgery office visit to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the neurosurgery office visit. You say that you have rare conditions that this 
out-of-network doctor specializes in treating these conditions. The Plan denied your request. The Plan says the 
provider is out-of-network 
 
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 provider at issue in this case is not a network provider with the Plan. 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 neurosurgery office visit. Our reviewer says that the service is not 
medically necessary. Our physician reviewer found the records indicate that you have only be seen by one in-
network provider and the Plan states there are other in-network providers available. 
 
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 neurosurgery office visit have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the neurosurgery office visit. Therefore, we decided 
that the Plan does not have to pre-approve the neurosurgery office visit 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 a portable oxygen concentrator to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested item.

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 item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator to be rendered by the out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 30, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on December 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantable auricular neurostimulator (L8679).
You asked the Plan to pre-approve the implantable auricular neurostimulator. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is not a covered benefit.
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. In this case, the implantable auricular neurostimulator is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the implantable auricular neurostimulator have not been met.
Therefore, we decided that the Plan does not have to pre-approve the implantable auricular neurostimulator (L8679).