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

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe SNF admission. You say that daily skilled care is required in this case.The Plandenied your request. The Plan says the enrollee is stable and does not need daily therapy to maintain her condition.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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 82 year old female who was admitted to IRF on 1/29 due to a lower medullary/cervical cord hemorrhage with tetraplegia. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. She received intermittent straight catheterization for neurogenic bladder. She was treated for a LLE DVT. Regarding rehabilitation services, the beneficiary received PT and OT in the acute hospital. The beneficiary was at a supervision to stand by assist level with functional mobility including gait to 250 feet with a rolling walker. The beneficiary required varying assist with ADLs.While the enrollee does have identifiable skilled nursing and therapy needs, these do not require these services on a daily basis. This beneficiary does 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 SNF 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peroral endoscopic myotomy (POEM) procedure for the enrollee.
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 enrollee has symptoms of daily solid and liquid dysphagia. Esophageal manometry on October 1, 2019 demonstrated EG junction outflow obstruction, but no evidence of achalasia. The requested POEM procedure is not considered experimental/investigational in nature; however, the procedure is not medically necessary for the enrollee. The records do not support a diagnosis of achalasia for the enrollee, but rather an esophageal motility disorder. Support in the peer-reviewed medical literature of the POEM procedure for the treatment of esophageal motility disorder is lacking. 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 peroral endoscopic myotomy (POEM) procedure for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.You asked the Plan to pre-approveadditional transportation. You say that you have no other way to get to dialysis.The Plan denied your request. The Plan says you have exhausted your transportation benefit.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 50 one-way trips per year. We looked at your request, the records in the case file, and the rules. Once you have used 50 one-way trips, you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on October 14, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says there was no valid proof of delivery in the documentation provided.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe dialysis treatments. You say that these services are medically necessary and this treating physician is in the best position to oversee the member's treatments.The Plan denied your request. The Plan says no medical need is shown as to why the member cannot get this care from a network provider.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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services 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 preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatmentwith an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have notbeen met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652)
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 for the enrollee.
You asked the Plan to pre-approve IRF care. 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. 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 reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 19, 2020 with acute lumbar radiculopathy. She underwent spinal surgery on February 23, 2020. She needs moderate assist for bed mobility and minimal assist for rolling and scooting. She is walking 20 feet with a rolling walker. She is medically stable with no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an intensive therapy program 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's needs could be met in a skilled nursing facility.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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer foundthe enrollee does not require medical oversight of his condition at an acute hospital level of care. His medical conditions appear stable and there are no complex wound care needs. While the enrollee requires physical therapy for mobility and occupationaltherapy for remaining activities of daily living and adaptive equipment, he has a primary rehabilitation diagnosis which does not support a need for an intensive therapy program. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.
You asked the Plan to pre-approve a wheelchair ramp. You say that you are wheelchair bound and cannot get in and out of the house. The Plan denied your request. The Plan says wheelchair ramps are statutorily excluded by Medicare.
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. Medicare does not cover home modifications. Also, the item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0675, E0673).You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolismis a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0675, E0673).
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-approvethe LTACH services. You say that the records provided support the need for LTACH care.The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of LTACH care. The Plan says that the services needed could be provided in another setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for multifactorial shortness of breath, in the setting of recently discovered lung masses. The enrollee is not intubated/ventilated. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no 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 Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
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 LTACH is medically necessary in this case. The Plan denied your request. The Plan says all necessary services can be provided in the current 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 patient is currently undergoing treatment at an ACH for a foot infection. The enrollee underwent amputation of a toe. He continues to receive wound care and a prolonged course 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 time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveComputed Tomography (CT) of the abdomen and pelvis.You asked the Plan to pre-approvethe CT scan. You say that the CT scan is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the records provided do not support that a CT scan is 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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approveComputed Tomography (CT) of the abdomen and pelvis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided from May 3, 2019 through May 31, 2019.
You asked the Plan to waive the copayment for wound debridement. You say that you feel that these were office visits. You say that your previous services only cost $25. The Plan denied your request. The Plan says the copayments applied correctly.
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 a $350 copayment per date of service for outpatient surgery at an outpatient hospital facility.
You have been asked to pay a total of $1,208.56 for wound debridement.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
May 3, 2019
Wound Debridement
$345.52
$350
$345.52
May 10, 2019
Wound Debridement
$345.52
$350
$345.52
May 17, 2019
Wound Debridement
$345.52
$350
$345.52
May 31, 2019
Wound Debridement
$172
$350
$172
TOTAL:
$1,208.56
Wound debridement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. Wound debridement is considered a surgical procedure. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for wound debridement provided from May 3, 2019 through May 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you require these specific stockings because they work the best for your circumstances with lymphedema that extends to your abdomen. The Plan denied your request. The Plan says these stockings are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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-approve compression stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine additional wound care clinic visits.You asked the Plan to pre-approve the additional visits. The Plan denied your request. The Plan says this is 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 the additional visits. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the medical records provided indicate that the enrollee's wound had not been evaluated by a physician and no plan of care had been established for the enrollee's wound care. The plan allowed the 1 visit for evaluation and informed that once the evaluation was completed, the new wound information could be submitted for a new review. The plan confirmed with the wound clinic that the member had not received the 1 evaluation visit at this time. The requested 9 additional wound care visits are not medically reasonable and 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 additional visits have not been met.Therefore, we decided that the Plan does not have to pre-approve nine additional wound care clinic visits
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for multiple medical procedures provided on October 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for multiple medical procedures. You say that you would like these claims paid due to these services being medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained 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 has network providers available who can provide 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 multiple medical procedures provided on October 5, 2019 by an out of network (OON) provider.