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

We decided that the Plan does not have to pre-approve an OmniSeq Insight Panel Test.
You asked the Plan to pre-approve an OmniSeq Insight Panel Test. You say that the records provided support the need for the requested testing. The Plan denied your request. The Plan says the requested testing panel is unlikely to impact therapeutic decision-making in the clinical management of the patient and is not considered 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 an OmniSeq Insight Panel Test. Our reviewer says that an OmniSeq Insight Panel Test is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of metastatic poorly differentiated T1cN2 adenocarcinoma of the lung, as well as stage 5 chronic kidney disease. There is evidence of worsening of metabolically active metastasis involving the right-sided pleural thickening, mediastinal lymph nodes, left lower lobe pulmonary nodule, and osseous lesion. Sequencing with NGS panel such as Omniseq INSIGHT was discussed. The OmniSeq INSIGHT genomic profiling is a 523 gene NGS panel. The documentation does not support that the OmniSeq Insight NGS panel testing would directly impact the treatment or management of the enrollee in this case. It has not been demonstrated that the number of genes or test are reasonable and necessary to obtain necessary information for therapeutic decision making. 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 OmniSeq Insight Panel Test have not been met. Therefore, we decided that the Plan does not have to pre-approve an OmniSeq Insight Panel Test.
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 the enrollee does not have documented skilled
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not
required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The
enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of
care.
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: 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 you need inpatient rehab. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness, dehydration and a urinary tract infection. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is necessary for the enrollee. The Plan denied your request. The Plan says based on the exam, the enrollee is able to self-propel a manual wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on January 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care services provided on January 30, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for ambulance response provided on February 2, 2021.
You asked the Plan to pay for ambulance response with no transport. You say that you cannot pay this bill and it should be covered by the Plan. The Plan denied your request. The Plan says the medical records clearly show you refused transport and response with no transport is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 2, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. With that said, per authority granted under the American Rescue Plan Act of 2021, the Centers for Medicare and Medicaid Service (CMS) has waived the requirements that an ambulance service must include transport to allow for treatment in place when transportation was not provided based on community-wide emergency medical service (EMS) protocols. This will require the ambulance provider to submit a claim for payment under this waiver. You may wish to contact the ambulance provider in this case to request that they submit a new claim for payment under this waiver to relieve some of this cost to you. However, at this time, the Plan does not have to pay for ambulance response with no transport provided on February 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) services to be provided in the home health setting.
You asked the Plan to pre-approve the requested home health services. You say that you feel that this is needed because you are homebound and need care. The Plan denied your request. The Plan says there is no evidence of the need for skilled services to be provided in the home setting. Requests for records to support the need for
this care was made of your physician and the home health agency and it was noted that only routine blood draws are required, which does not qualify as a skilled service.
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. Your physician and home health agency declined to submit records to support the medical necessity of the requested services. The limited documentation available does not indicate that services that can only be provided by a skilled nurse or therapist are required. Without documentation from your treating physician, it cannot be determined whether criteria for home health services have been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) services to be provided in the home health setting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power mobility device features (E2300 and E2331).
You asked the Plan to pre-approve the mobility device features. You say that the features should be covered. The Plan denied your request. The Plan says they will overturn the request for a group 3 power wheelchair, but not the seat elevation feature (E2300) or attendant control (E2331) are not covered.
The Plan follows Medicare rules. Medicare rules say that power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. The rules also say that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. Therefore, we decided that the Plan does not have to pre-approve a group 3 power mobility device features (E2300 and E2331).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the enrollee does not require skilled services on a daily basis or skilled rehabilitation services.
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 SNF care is medically reasonable and necessary for the enrollee in this case. The member has stabilized medically and is ready for discharge from the hospital. Although the member does not have any skilled nursing needs, she has had a significant decline in physical functioning after her recent fall with compression fracture of the spine. The member does require skilled therapy services on a daily basis at a skilled nursing facility to restore function and avoid further decline or complications. She was previously independent with mobility and self-care tasks and lives alone, currently she requires hands-on assistance for mobility and self-care tasks. Our physician reviewer found that the enrollee's condition meets Medicare criteria for SNF care. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract surgery and canaloplasty and trabeculotmy.
You asked the Plan to pre-approve cataract surgery and canaloplasty and trabeculotmy. You say that the requested items/services are medically reasonable and necessary in this case. The Plan denied your request. The Plan says the requested items/services are not considered medically reasonable and necessary in this case.
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 cataract surgery and canaloplasty and trabeculotmy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was undergoing evaluation for cataracts and glaucoma. On 6/30/21, the enrollee's best corrected visual acuity was 20/20. Pressures were 17 in the right eye and 19 in the left eye, both within the normal range. The documentation does not support that the enrollee has cataracts causing symptomatic impairment of visual function which is not correctable with a tolerable change in glasses or contact lenses, resulting in specific activity limitations and/or participation restrictions including, but not limited to reading, viewing television, driving, or meeting vocational or recreational needs. The remaining coverage criteria are not met. The enrollee's intraocular pressure is documented to be within the normal range. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cataract surgery and canaloplasty and trabeculotmy have not been met. Therefore, we decided that the Plan does not have to pre-approve cataract surgery and canaloplasty and trabeculotmy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377) with expandable harness (E2313) and electronic connection (E2311), a seat lift (E2300) and push handles (K0108).
You asked the Plan to pre-approve an expandable controller (E2377) with expandable harness (E2313) and electronic connection (E2311), a seat lift (E2300) and push handles (K0108) You say that the requested items/services are medically reasonable and necessary in this case. The Plan denied your request. The Plan says the requested items/services are not considered medically reasonable and necessary in this case.
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 an expandable controller (E2377) with expandable harness (E2313) and electronic connection (E2311), a seat lift (E2300) and push handles (K0108). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the E2311, E2377 Expandable Controller and E2313 Expandable Controller Harness are not medically necessary per Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to feed himself indicates that the enrollee can control any power options through their own individual switches. Furthermore, Medicare specifically excludes coverage of power seat elevation systems coded as E2300. Medicare also does not cover the requested push handles coded as K0108 as these do not serve a medical purpose. 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 (E2377) with expandable harness (E2313) and electronic connection (E2311), a seat lift (E2300) and push handles (K0108). have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with expandable harness (E2313) and electronic connection (E2311), a seat lift (E2300) and push handles (K0108).
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 an IRF admission is medically necessary. The Plan
denied your request. The Plan says an IRF admission is not medically necessary. You can safely receive the
services you need in other settings, for example: 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 in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does require
physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation
that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction provided on December 31, 2020.
You asked the Plan to pay for the surgical extraction. You say that the treating provider advised that this was a simple tooth extraction. You also say that the extraction was provided using only Novocaine and took five minutes. The Plan denied your request. The Plan says surgical extractions are not covered under your plan. The Plan also says that you were aware that the procedure was not covered under your plan and paid for the extraction at the time of the visit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The only type of extractions covered under your plan are simple extractions. Therefore, we decided that the Plan does not have to pay for the surgical extraction provided on December 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses provided on February 22, 2021.
You asked the Plan to pay for the knee orthoses. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not support the need for the supplied items.
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 does not contain relevant medical records which support medical necessity for the supplies provided in this case. Review of the file shows that the documentation submitted did not indicate that the provider discussed the need for the billed supply code; therefore, the billed supply code cannot be verified. The record
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthoses provided on February 22, 2021.