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

We decided that the Plan does not haveto pre-approvecontinued skilled nursing facility (SNF) services.You asked the Planto pre-approve the services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe skilled records received indicate that baseline functioning level has been indicated.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 Planwas correct in denying the request to pre-approve the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Medtronic 670G Minimed system sensors.
You asked the Plan to pre-approve the sensors. You say that this is medically necessary. The Plan denied your request. The Plan says that these supplies are not covered for a continuous glucose monitor.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 sensors. Our reviewer says that the requested sensors are medically reasonable and necessary. Our physician reviewer found you have requested sensors to be used with your Minimed 670G system (an FDA approved, combined insulin pump and CGM). The health plan has denied the sensors stating that they are not to be used with a Medicare covered CGM. The health plan has not argued that the use of either an insulin pump or a CGM is not medically necessary for this enrollee. The use of a single device that acts as both an insulin pump and a CGM, rather than using two separate devices, is reasonable. 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 sensors have been met. Therefore, we decided that the Plan has to pre-approve Medtronic 670G Minimed system sensors.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says SNF admission 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are is still undergoing your medical evaluation. You have not yet undergone a rehabilitation evaluation. Therefore, there is no documentation to support that daily skilled services are required to establish a maintenance program or to prevent deterioration of your condition. 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) admission.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond January 16, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that you feel that the enrollee needs more SNF care to improve her level of function. The Plan denied your request. The Plan says her needs are custodial and daily therapy is not needed 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 79 year old female with dementia with hip pain admitted to the SNF on December 23, 2019. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. She was alert with confusion. Regarding rehabilitation services, the beneficiary received PT, ST and OT in the SNF. By the dates in question, the beneficiary was at a minimal to moderate assist level with functional mobility including gait to 250 feet. The beneficiary required varying assist with ADLs. She tolerated a regular diet and thin liquids. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond January 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee's needs could be met at a lower level of 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 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 found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee may not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation 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 IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve a bath seat.You asked the Planto pre-approve the bath seat. You say that you feel that this should be covered due to your medical condition.The Plandenied your request. The Plansaysthis is not covered by Medicare as it is not a medical device.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 Plandoes not haveto pre-approvea bath seat
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent. You asked the Plan to pre-approve Dupixent. You say that the enrollee has demonstrated a beneficial clinical response.The Plan denied your request. The Plan says Dupixent to be administered at home is not covered under the Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Dupixent.Benefits for Dupixent may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 treatment with an E0650 or E0651. At leastfour 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 not been 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: Drugs
Decision: Unfavorable

We decided that the Plandoes not have to pre-approveGelsyn-3 injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested drug is subject to step therapy.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the provided medical records do not indicate that the enrollee has tried and failed the required drugs. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approveGelsyn-3 injection for the enrollee
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the cost for the cardiac catheterization provided on July 18, 2019.You asked the Plan to reduce the cost for the cardiac catheterization. You say that you thought this was considered an outpatient procedure. You say that you should only have a $325 copayment.The Plan denied your request. The Plan says that the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $325 copayment for each in-network Medicare-covered outpatient hospital visit and hospital outpatient surgical facility.The Plan says you must pay 20% coinsurance for the cardiac catheterization. Based on the Plan contract, however, you cannot be asked to pay more than a $325 copayment for the cardiac catheterization.Therefore, we decided that the Plan has to reduce the cost forthe cardiac catheterization provided on July 18, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan has to pay for the armrests (E0973). We decided that the Plan does not have to pay for the foam tires (E2386). You asked the Plan to pay for the armrests (E0973). You say that the wheelchair accessories were ordered and provided.The Plan says that the records do not support the accessories billed.We decided that the Plan has to pay for the armrests (E0973).The arm rests were ordered, provided,and signed for.We also decided that the Plan does not have to pay for the foam filled drive wheel tires(E2386).There is no physician order for the tire upgrade.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair and attachments for the enrollee.You asked the Plan to pre-approvethese services. You say that the patient is a fall risk and needs this chair.The Plan denied your request. The Plan says that the patient can use a standard wheelchair since he has use of bilateral upper extremities.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:1. A neurological condition;2. Myopathy; or3. Congenital skeletal deformity.The file does not show that  has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have to pre-approvea Group 3 power wheelchair and attachments for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to approve continued skilled nursing facility (SNF) services beyond
January 18, 2020 for the enrollee.
You asked the Plan to approve these services. You say that the enrollee needs more care. The Plan denied your
request. The Plan says the enrollee has exhausted the benefit limit.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 5, 2019 to
January 18, 2020. The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not
been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that
the Plan does not have to approve continued skilled nursing facility (SNF) services beyond January 18, 2020
for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plan denied your request. The Plansaysthe services can be safely received in another setting.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 found your baseline level of function is unclear. Your ability to perform fifteen hours per week of skilled therapy has not been established. Assuming you can perform fifteen hours per week of skilled therapy, the documentation does not establish that you need fifteen hours per week of rehabilitative services and regular provider evaluation. It appears that your care needs can be met at a lower level of care (ex. SNF/SAR).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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF)
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for your routine transportation.
You asked the Plan to pre-approve additional miles. You say that your car is not working, and your foot is in a boot. The Plan denied your request. The Plan says your benefit only allows 50 miles.
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 file shows that you requested transportation for cover 50 miles. We looked at your request, the records in the case file, and the rules. Your plan only covers one-way trips for up to 50 miles. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional mileage for your routine transportation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe skilled nursing visits to be provided by "the provider". You asked the Plan to pre-approvethe skilled nursing visit. You say that you have chronic illnesses and you need an aid to help you with bathing, cooking, cleaningand  getting from one place to another.The Plan denied your request. The Plan says the requested service has been found to be 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 skilled nursing visit. Our reviewer says that this enrollee does not meet the criteria for the 1 skilled nursing visit. Our physician reviewer found the records do not show a furtherdecline in functional or medical status or care plan to warrant the one skilled nursing visit. One skilled nursing visit is not required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing visit have not been met.Therefore, we decided that the Plan does not have to pre-approve the skilled nursing visits to be provided by "the provider".
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAranesp injections.You asked the Planto pre-approvethe Aranesp. You say that the enrollee has low hemoglobin and needs Aranesp to increase this level.The Plan denied your request. The Plansaysthe use of Aranesp is only allowed if Retacrit is tried and failed.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Aranesp. Our reviewer says that the requested drug is not medically reasonable and necessary based on step therapy rules. Our physician reviewer found the enrollee is a female with pancytopenia, myelofibrosis, and anemia. The records do not show that Retacrit has been tried/failed. The provided medical records do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Aranesp have not been met.Therefore, we decided that the Plan does not have to pre-approveAranesp injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug provided by "the provider" on July 11, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on July 11, 2019. The allowed amount is $1,387.11 and 20% of that is $277.42. You have been asked to pay the total coinsurance amount of $277.42 for a Medicare Part B drug. A Medicare Part B drug 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 coinsurance fora Medicare Part B drug provided by "the provider" on July 11, 2019.