Persius/hicric huggingface dataset:
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 and/or
skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a
lower level of care. Although further rehab services would be appropriate to improve function, as a practical
matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 13 additional physical therapy services in the home
health or hospice setting, each 15 minutes, and 1 additional occupational therapy visit in the home health or
hospice setting, each 15 minutes, from March 9, 2021, to April 1, 2021.

You asked the Plan to pre-approve the home health services. You say that you need these services. The Plan
denied your request. The Plan says that the home health services are not medically necessary.

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.

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 home health services. Our reviewer
says that the requested home health services is not medically necessary. Our physician reviewer found the
documentation does not support that you require additional skilled rehab services to provide treatment that is
medically necessary. The reviewer found that you do not require additional rehabilitation services to effectively
provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to
maintain your condition and/or prevent deterioration. The reviewer found that you have been medically stable
without any recent exacerbations of chronic medical problems or hospitalizations. The reviewer found that you
have improved with therapy and have been instructed regarding a home exercise program. The reviewer found
that you required ongoing custodial care. Therefore, the reviewer found that the requested home health services
are 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 the home health services have not been met. Therefore, we decided that the Plan
does not have to pre-approve 13 additional physical therapy services in the home health or hospice setting, each
15 minutes, and 1 additional occupational therapy visit in the home health or hospice setting, each 15 minutes,
from March 9, 2021, to April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve supplies for a CGM (K0553).

You asked the Plan to pre-approve CGM supplies. You say that the requested item is a necessity for the enrollee. The Plan denied your request. The Plan says rules for CGM supplies have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day nor use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve supplies for a CGM (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve routine transportation. You say that you cannot drive or walk on your own and there is no one that can take you to appointments. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 24 one-way trips per year is not covered by the Plan.

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 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 pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames (V2020, V2025) received on September 22, 2020.

You asked the Plan to pay for frames. You say that you did not know that you had to use the Plan's vision provider. The Plan denied your request. The Plan says reimbursement was denied because an out-of-network provider rendered the service.

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 covers routine eyewear when the Plan network provider is utilized. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of frames have not been met. Specifically, services were provided by an out-of-network provider. The Plan has network providers available to provide these services. 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 frames (V2020, V2025) received on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery and coinsurance for
an injection provided by a participating provider on October 1, 2020, to October 22, 2020.

You asked the Plan to waive the copayment for an outpatient surgery and coinsurance for an injection. You say
that you already met your out-of-pocket maximum. The Plan denied your request. The Plan says the correct
charges have been applied.

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 $225
copayment for outpatient surgery/outpatient surgery and a 20% coinsurance for Medicare Part B prescription
drugs.

You have been asked to pay less than a $225 copayment for an outpatient surgery and a 20% coinsurance for
an injection.

Total Amount Being Asked to Pay: $1,497.97 ($714.34 + $53.33 + $676.97 + $53.33).

Your out-of-network maximum was met after October 22, 2020. An outpatient surgery falls within the
outpatient surgery/outpatient surgery benefit category and an injection falls within the Medicare Part B
prescription drugs benefit category. 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 an outpatient surgery
and coinsurance for an injection provided by a participating provider on October 1, 2020, to October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower/bath chair.

You asked the Plan to pre-approve a shower/bath chair. You say that the requested item is imperative for the enrollee. The Plan denied your request. The Plan says the requested item is not a Medicare or Plan benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower/bath chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction.

You asked the Plan to pre-approve the dental service. You say that the enrollee was in a skilled nursing facility for 3 plus months. You say that no one was helping the enrollee brush her teeth. You say that decay has rotted the enrollee's teeth as a result. You say that the teeth need to be extracted. You say that you believe that this is more of a medical issue. You also say that this is an emergency. The Plan denied your request. The Plan says the requested services are dental in nature. The Plan says that routine dental services are not covered by Medicare.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The service you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an extraction.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituxan.

You asked the Plan to pre-approve Rituxan. The Plan denied your request. The Plan says that the off-label use
for the drug is not medically accepted for the enrollee's condition.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Rituxan. Our physician reviewer found
that the enrollee is being treated for chronic active kidney transplant rejection. The requested use of Rituxan is
not FDA-approved for the enrollee's diagnosis. However, the use is supported by clinical research that appears
in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended
in any of the compendia. The documentation does support that the requested drug is safe and effective and
otherwise reasonable and necessary for this 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 Rituxan have been met. Therefore, we decided that the Plan has to pre-approve
Rituxan.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. You are presenting to the hospital for an elective reverse shoulder arthroplasty after having shoulder pain related to glenoid dysplasia and arthropathy having failed conservative treatment. This procedure is not listed as an inpatient only procedure, and your medical history does not suggest a likely complication or complex recovery to estimate a hospital stay that would likely cross two midnights. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient hospital services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
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 there are no services offered at a SNF that are
not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a zero gravity chair.

You asked the Plan to pre-approve a zero gravity chair. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a zero gravity chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless hand rehabilitation device.

You asked the Plan to pre-approve a wireless hand rehabilitation device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a wireless hand rehabilitation device is non-covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a wireless hand rehabilitation device have not been met. Therefore, we decided that the Plan does not have to pre-approve a wireless hand rehabilitation device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the weight-lifting terminal device (L7499).

You asked the Plan to pre-approve the weight-lifting terminal device. You say that the result of using this terminal device with his prostheses will translate to many overall benefits in his daily life. It is medically necessary for the enrollee to have this terminal device. The Plan denied your request. The Plan says this item is intended to aid in recreational weight-lifting and is not a covered benefit.

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 weight-lifting terminal device (L7499).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that this is the next step for the enrollee to fully recover. The Plan denied your request. The Plan says the enrollee does not require an interdisciplinary approach to rehab 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 physician reviewer found that the enrollee is at a moderate to maximal assist level for standing up, and at total assist to fasten brief and don socks. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation.

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 IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's medical condition requires further evaluation and treatment in the acute care hospital.

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 physician reviewer found that the enrollee is at a minimal assist level for rolling, sitting up, standing up, bed-to-chair transfer, and walking using a two-wheeled walker. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services.

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 long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that it is felt that LTACH would be the best option for the enrollee. The Plan denied your request. The Plan says the enrollee's condition has improved and a higher level of care is not warranted at this time.

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 necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 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.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from a transfer to a LTACH hospital so he can get the appropriate level of care he needs. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 for the enrollee.