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

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found there is no documentation that the patient
requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional
nurse are not required to safely and effectively provide medically necessary and reasonable treatment. This
patient does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified
therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily
skilled services are not required. This patient does not require the services on an inpatient basis, only in a
skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020) and polycarbonate lenses (V2784) provided on October 20, 2020.

You asked the Plan to pay for eyeglass frames and polycarbonate lenses. You say that you were able to get your eyeglasses for a fraction of the cost from an in-network provider. The Plan denied your request. The Plan says they requested proof of payment and it has not been received.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that if you have already paid for services or drugs covered by the plan, you can ask our plan to pay you back.

We looked at your request, the file and the rules. Based on this information we have determined that coverage criteria for frames and lenses have not been met. Specifically, the record does not include sufficient documentation to determine if payment has been made for the billed services. Of note, the record indicates that the Plan has requested proof of payment and has not yet received it. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames and polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020) and polycarbonate lenses (V2784) provided on October 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an unlisted shoulder procedure (23929) provided on January
23, 2021.

You asked the Plan to pay for an unlisted shoulder procedure. You say that this is supported in the records. The
Plan denied your request. The Plan says the records do not document what this code was used for.

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, the CPT Code Manual definition of code 23929 is unlisted procedure, shoulder.

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 an unlisted shoulder procedure. Our
reviewer says that this code is not supported. Our physician reviewer found the operative report does not
document what the unlisted procedure is used for.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an unlisted shoulder procedure have not been met. Therefore, we decided that
the Plan does not have to pay for an unlisted shoulder procedure (23929) provided on January 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar spinal fusion at levels L3-4 and L4-5.

You asked the Plan to pre-approve lumbar spinal fusion at levels L3-4 and L4-5. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 lumbar spinal fusion at levels L3-4 and L4-5. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no spinal instability documented at levels L3-4 and L4-5. Criteria for fusion is not met at these levels. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar spinal fusion at levels L3-4 and L4-5 have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spinal fusion at levels L3-4 and L4-5.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in-home assistance services.

You asked the Plan to pre-approve the services. You say that the enrollee is bedridden and had a stroke with residual neurological deficit. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

The requested services do not appear to be skilled and would be considered custodial care. 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 in-home assistance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bag hooks (K0108) and an expandable controller (E2377) with harness (E2313) and electronic connection (E2311).
You asked the Plan to pre-approve bag hooks and an expandable controller with harness and electronic connection. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested items 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. The rules also say that for equipment to be covered it must primarily serve a medical purpose. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an expandable controller with harness and electronic connection. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation that the enrollee meets Medicare criteria for an expandable controller with harness and electronic connection. Records indicate the enrollee has 4+ to 5/5 upper extremity strength and is independent with feeding and meal preparation, thus indicating that the enrollee has adequate upper extremity strength and function to operate the power options with their own switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller with harness and electronic connection have not been met. Bag hooks do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve bag hooks (K0108) and an expandable controller (E2377) with harness (E2313) and electronic connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on December 14, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on January
19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional physical therapy (PT) visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that the patient would benefit from continued therapy 2 times a week for 2 weeks to complete the functional gains she has begun to obtain with therapy up to this point. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 ten (10) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in and is independent in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 based on the medical records provided there is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gallium-68 prostate-specific membrane antigen
(PSMA) positron emission tomography (PET) scan.
You asked the Plan to pre-approve a Gallium-68 PSMA PET scan. You say that the services are necessary. The
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage
criteria have not been met.
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 a Gallium-68 PSMA PET scan. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the requested service is considered experimental and investigational. The
requested service is not medically necessary and reasonable as defined by Medicare rules. The elements of the
coverage criteria are not satisfied. The requested service cannot be recommended.
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 Gallium-68 PSMA PET scan have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Gallium-68 prostate-specific membrane antigen (PSMA) positron
emission tomography (PET) scan.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care
Appeal type: Supplemental Benefit
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare does not pay for hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids. You can find this rule at 42 CFR Section 411.15(d).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that the Plan covers a maximum Plan benefit amount of $1500 per ear, every three years for hearing aid and fitting. You can find this information on page 71 of the Plan's 2020 Evidence of Coverage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network
(OON) provider on February 16, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on
February 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from August 9, 2021, forward.
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient 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 beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a SNF setting beyond the last covered date. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from August 9, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, harness, and electrical
connection for a power wheelchair.
You asked the Plan to pre-approve power wheelchair components. You say that you are appealing this denial.
The Plan denied your request. The Plan says the denial of authorization for these components is correct,
because your wheelchair's power options can be controlled using their own switches.
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 power wheelchair components. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found the documentation does not reveal that you require other types of
proportional input devices or non-proportional input devices. You do not need to operate 3 or more powered
seating actuators through the drive control, a separate display, other electronic device, or attendant control.
Your strength and function in the upper extremities indicate that you can control your wheelchair's power
options through their own individual switches.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of power wheelchair components have not been met. Therefore, we decided that
the Plan does not have to pre-approve an expandable controller, harness, and electrical connection for a power
wheelchair.