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

We decided that the Plan does not have to pre-approveRetacrit.You asked the Plan to pre-approveRetacrit. You say that Retacrit is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of Retacrit.The Plan follows Medicare rules. The rules state that ESA treatment is not reasonable and necessary for beneficiaries with certain clinical conditions.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 Retacrit. Our reviewer says that Retacrit is not medically necessary at this time. Our physician reviewer found this patient has a very high risk myelodysplastic syndrome (MDS). The use of epoetin alpha isn't recommended for patients with high risk or very high risk MDS. It is only recommended in low risk MDS. The service is not reasonable or 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 Retacrit have not been met.Therefore, we decided that the Plan does not have to pre-approveRetacrit.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that the SNF services are medically necessary as the member is unable to care for himself. The Plan denied your request. The Plan says the member does not have any skilled nursing or skilled therapy needs.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not meet severity of illness or intensity of service criteria for an inpatient basis in an SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOne Touch Verio Test Strips (A4253).You asked the Plan to pre-approveOne Touch Verio Test Strips (A4253). You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says they have approved a 3 month supply with no refills for the requested One Touch Verio test strips to help transition to a preferred brand covered by the Plan.The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations.We looked at the file, the Plan's contract and Medicare rules. The Plan contract clearly states alternate non-preferred brand diabetic supply products are not covered unless a doctor provides adequate information that the use of an alternate brand is medically necessary in the enrollee's specific situation. The file does not provide documentation from your treating physician that the requested non-preferred brand, One Touch Verio test strips are medically necessary. Based on this information, we decided that Medicare rules for coverage of One Touch Verio Test Strips (A4253) have not been met.Therefore, we decided that the Plan does not have to pre-approveOne Touch Verio Test Strips (A4253).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued inpatient psychiatric hospital care.You asked the Plan to pre-approveinpatient psychiatric hospital care. You say that the enrollee is unable to live independently and is currently waiting to be accepted into a rehabilitation program.The Plan denied your request. The Plan says the denial of authorization for continued inpatient psychiatric hospital care is correct.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 psychiatric hospital care. Our reviewer says that the enrollee doesnot meet the Medicare criteria for inpatient psychiatric hospital care. Our physician reviewer found based upon the records provided it was not expected that the enrollee would improve in a reasonable period of time as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment and found to be calm, friendly, happy, and relaxed. It does not appear medically necessary and reasonable to have psychiatric care provided at theacute inpatient level of care rather than a lower level of care at this point. The Plan's denial of continued inpatient psychiatric services is appropriate. It does not appear that active treatment was taking place beyond the date in question. The record does not include an individualized treatment plan; however, the enrollee's entire record is not present. It does appear that the services are supervised and evaluated by a physician.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 psychiatric hospital care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient psychiatric hospital care.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital discharge day management provided on August 22, 2019.You asked the Plan to pay forthe hospital discharge day management. You say that the enrollee was not enrolled in hospice care while they were in the hospital, but was discharged to hospice.The Plandenied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe hospital discharge day management provided on August 22, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower wheelchair electronic upgrades.You asked the Plan to pre-approvethe power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the enrollee needs the upgraded electronics to control the features.The Plan denied your request. The Plan says the notes do not show a medical need to control the power options trough the joystick.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 power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). Our physician reviewer found these accessories donot markedly enhance the function of a standard power mobility device and would not appear to markedly enhance the mobility related activities of daily livingperformance for this enrollee. They are convenience items and deemed not medically necessary.We looked at this physician's review, the file, and Medicare rules. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. The power options come with their own switches. Based on this information, we decided that Medicare rules for coverage of the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) have not been met.Therefore, we decided that the Plan does not have to pre-approvepower wheelchair electronic upgrades.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe arthrocentesis provided on September 26, 2019.You asked the Plan to waive the copayment forthearthrocentesis. You say that you previously had the same procedure and were charged less. You say that the cost should be the same.The Plan denied your request. The Plan says the copayment 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 $250 copayment for each Medicare-covered outpatient hospital facility visit.You have been asked to pay $238.55, which is less than the standard $250 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forthe arthrocentesis provided on September 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.You asked the Plan to pre-approve the SNF admission. You say that you are not ready to go home as you are unable to eat solid foods or swallow properly. The Plan denied your request. The Plan says your needs may be met at a lower level of care.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 notcovered.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 your care can be appropriately provided through home-based and outpatient 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forfoot orthotics.You asked the Plan to pay forfoot orthotics. You say that you were informed by the provider that the Plan does not cover orthotics. However, you say your previous Plan had covered orthotics for the enrollee before. You say that the enrollee has Crohn's disease and it was recommended that the enrollee walk daily. Due to the enrollee's plantar fasciitis, you say the orthotics are necessary.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition.Therefore, we decided that the Plan does not have to pay forfoot orthotics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that SNF care is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of SNF care.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 this patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF The patient does not have a tracheostomy tube, complex wound care or other SNF level skilled nursing need. This patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveleft genicular nerve blocks.You asked the Plan to pre-approveleft genicular nerve blocks. You say that the requested left genicular nerve blocks are medically necessary.The Plan denied your request. The Plan says the requested left genicular nerve blocks 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 left genicular nerve blocks. Our reviewer says that the requested left genicular nerve blocks are not medically necessary. Our physician reviewer found the member was seen on 11/05/2019 with complaintsof bilateral knee pain. She had undergone intra-articular steroid injections in both knees with about 60% pain relief which was ongoing on the right. Her left knee was still quite painful. She had been told she was a candidate for total knee replacement but needed to lose 25 pounds to be a candidate. Treatments had also included viscosupplementation without lasting relief. She was interested in a genicular radiofrequency procedure which she wanted to consider on the left as her left knee was the most painful. Physical examination findings included obesity with a body mass index of 42. The treatment plan included left knee genicular blocks under fluoroscopic guidance. She underwent blocks on 12/10/2019 and on 01/06/2020.Genicular radiofrequency ablation and genicular nerve blocks are considered experimental, investigational and unproven for the treatment of chronic knee pain, including degenerative joint disease or osteoarthritis of the knee; as a treatment prior to or following a knee replacement, or as a treatment for individuals who are not candidates for knee replacement surgery. The safety and/or effectiveness of this procedure has not been established by review of the available published peer-reviewed literature.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of left genicular nerve blocks have not been met.Therefore, we decided that the Plan does not have to pre-approveleft genicular nerve blocks.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for catheter insertion (36558), ultrasound guidance for vascular guidance (76937), fluoroscopic guidance for central venous access device placement (77001) and radiation exposure indices (G9500) provided on August 28, 2019.You asked the Plan to pay for catheter insertion, ultrasound guidance, fluoroscopic guidance and radiation exposure indices. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim submitted shows the member's place of treatment as "Outpatient Hospital" while the member was inpatient.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code  is not supported in the record. Specifically, the record indicates that the member was inpatient on this date of service. The claim submitted records the place of service as 22 or outpatient hospital. Based on this information, we decided that Medicare rules for coverage of catheter insertion, ultrasound guidance, fluoroscopic guidance and radiation exposure indices have not been met. Therefore, we decided that the Plan does not have to pay for catheter insertion (36558), ultrasound guidance for vascular guidance (76937), fluoroscopic guidance for central venous access device placement (77001) and radiation exposure indices (G9500) provided on August 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for  roadside assistance received on August 22, 2019.
You asked the Plan to pay for the roadside assistance. You say that the provider is considered a qualifying club. The Plan denied your request. The Plan says this does not fall under the category of "qualified health club or fitness facility."
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The plan rules state that $200 can be paid per year towards the cost of a membership in a qualified health club or fitness facility. Roadside assistance is not a medical service. Based on this information, we decided that Medicare rules for coverage of the roadside assistance have not been met. Therefore, we decided that the Plan does not have to pay for roadside assistance received on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora hearing aid provided on July 18, 2019.You asked the Plan to pay forthe hearing aids. You say that the hearing aid is intended to primarily be used withcochlear implant users.The Plan denied your request. The Plan says there is no coverage of hearing aids or related services if they are received from an out-of-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 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 a network provider available (hi HealthInnovations) 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 payfor these items/services.Therefore, we decided that the Plan does not have to pay fora hearing aid provided on July 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to payforthe skilled nursing facility (SNF) services rendered from July 25, 2019 to August 23, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan saysthe services were 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 pay for these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee wastransferred to the SNF for long-term care. She received oral and topical medications and received physical and occupational therapy. By the dates in question, she needed supervision for functional mobility, including gait to 200 feet with a rolling walker. She needed varied assist with activities of daily living. She had no skilled nursing needs. She had skilled therapy needs but did not require skilled therapy on a daily basis. As a practical matter, the enrollee did not require the necessary services on an inpatient basis at the SNF level of care for the dates of service at issue.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 pay forthe skilled nursing facility (SNF) services rendered from July 25, 2019 to August 23, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay forvision care services provided on August 14, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthere was no authorization for the 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 Plandoes not haveto pay forvision care services provided on August 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on May 2, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay forthe drug testing rendered on May 2, 2019.