Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on May 29, 2019.You asked the Plan to pay forthe orthosis and sleeve. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.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 the orthosis and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthosis and sleeve ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.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 orthosis and sleeve have not been met.Therefore, we decided that the Plan does not have to pay forknee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on May 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Flexitouch pneumatic compression device.You asked the Plan to provide a pneumatic compression device (E0652). You say that despite utilization of a basic pump the enrollee continues to have bilateral lower limb and truncal swelling.The Plan denied your request. The Plan says there is no documentation of a four-week trial but the brief use of the basic pump showed improved values.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 least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. The record does not show truncal or abdominal edema, or a four-week trial. 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 provide a Flexitouch pneumatic compression device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be rendered in 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 the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care. A less intensive, longer duration of therapy may be more
appropriate. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed and alternating pressure mattress.
You asked the Plan to pre-approve a total electric hospital bed and alternating pressure mattress. You say that a total electric hospital bed and pressure mattress are medically necessary and beneficial. The Plan denied your request. The Plan says the height adjustment feature is a convenience feature not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed and alternating pressure mattress.
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 admission. 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvetransthoracic echocardiography for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no documentation provided showing new, recurrent, or worsening symptoms.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has known coronary disease but no history of valvular heart disease, no LV dysfunction on prior testing, no cardiac symptoms, a normal cardiovascular physical exam, and no changes on electrocardiography. In this circumstance the records do not support the medical necessity for an echocardiogram. Coverage criteria for an echocardiogram are not met, since there are no documented covered indications for the procedure.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-approvetransthoracic echocardiography for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
You asked the Plan to pre-approve a Group 3 power wheelchair and accessories. You say that a power wheelchair is medically necessary for the enrollee to be independent within the facility and improve quality of life. The Plan denied your request. The Plan says Medicare guidance says that coverage cannot be provided for equipment used in a Skilled Nursing Facility.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that a Group 3 power wheelchair and accessories is being requested for use in a SNF. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.You asked the Plan to pre-approvethese services. You say that the enrollee needs basic care and skilled therapy.The Plan denied your request. The Plan says the 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 11, 2020 with altered mental status. He received oral medications and had stable vital signs. He received physical therapy in the hospital and needs supervision to maximum assistance with bedmobility. Therapy was limited by cognitive impairment. He has no skilled nursing or skilled therapy needs. He does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary serviceson an inpatient basis at the SNF 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a sleep study (95810).
You asked the Plan to pre-approve a sleep study. You say that this is needed to help the enrollee with sleepiness, fatigue, sleep apnea, and chronic obstructive pulmonary disease (COPD). The Plan denied your request. The Plan says that this is not medically necessary.
The plan follows Medicare rules. Medicare rules say that diagnostic testing is covered only if the patient has the symptoms or complaints of one of the conditions listed 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 a sleep study. Our reviewer says that this is medically necessary. Our physician reviewer the enrollee has symptoms suggestive of obstructive sleep apnea and is on narcotics for chronic pain, substantially increasing the risk for sleep disordered breathing, including central apnea. He also has severe COPD, requiring intubation in 2018, and may be experiencing nocturnal hypoventilation related to this. The sleep study must be done attended, in-lab because of the severe COPD. He may require Bilevel Positive Airway Pressure (BiPAP) support, but given his previous intolerance of BiPAP, it is reasonable to establish an accurate sleep diagnosis, and if there is a need for PAP, then work on solving issues with the interface.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sleep study have been met. Therefore, we decided that the Plan has to pre-approve a sleep study (95810).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110), neuromuscular re-education (97112) and electrical stimulation (G0283) provided on July 24, 2019 through August 8, 2019.
You asked the Plan to pay for the therapeutic exercises, neuromuscular re-education and electrical stimulation. You say that you were not aware that you were receiving non-covered services. The Plan denied your request. The Plan says these services are not approved or payable by Medicare.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110), neuromuscular re-education (97112) and electrical stimulation (G0283) provided on July 24, 2019 through August 8, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ixempra for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective, and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has stage IVA primary peritoneal carcinoma. Ixempra is not FDA-approved for ovarian or primary peritoneal cancers; however, use in certain populations such as platinum and taxane resistance is supported by the medical literature. The enrollee has shown progression through standard therapies and molecular profiling did not reveal any novel targets. Ixempra is therefore reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Ixempra for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee would benefit from daily skilled therapy. The Plan denied your request. The Plan says the enrollee's needs are custodial and he does not require daily skilled services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted with aphasia and left sided weakness found to have had a stroke. Per records as of 2/3/2020, the patient was supervision for bed mobility, supervision for transfers, and he was ambulating 200 feet with supervision and no assistive device. 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. 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 only 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit 20,000 units/ml vial for the enrollee.You asked the Plan to pre-approvethe drug. You say that this is medically necessary.The Plan denied your request. The Plan says the off-label use of this drug is not accepted for the enrollee's condition.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer foundthe pre-authorization request for Procrit notes anemia is associated with a diagnosis of myasthenia gravis without exacerbation. Reviewed documentation does not include a provider statement, office note, or laboratory test results. Review of Medicare approved compendia does not support the use of Procrit for this diagnosis. Without the support of the documentation, medical necessity cannot be determined.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 drug have not been met.Therefore, we decided that the Plan does not have to pre-approveProcrit 20,000 units/ml vial for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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 that Medicare coverage criteria are not met.
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. 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 Medicare coverage criteria are met. Our physician reviewer found the records show a need
for both daily skilled therapy and nursing services. At this point there is an inability to perform essential
activities of daily living such as bed mobility or transfer without assistance. The recent cardiac defibrillator
surgery and findings of bilateral upper extremity deep vein thrombosis would be expected to limit the ability to
effectively use a two-handed assistive device. The current condition would be expected to deteriorate with
services provided on a less than daily basis. There is a reasonable expectation of a reduction in burden of care
with a goal of a successful return to the community through the SNF level care being requested. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on August 30, 2019.
You asked the Plan to pay for the hearing aids. You say that you called the 800 number to get more information and found they are located nearly 200 miles south of where you live so you went to your primary for a referral to a local hearing aid center. The Plan denied your request. The Plan says they made outreach to the provider on December 12, 2019 and spoke with someone who advised you came with a referral for a hearing test and were aware that the provider was not contracted with the plan, so you
paid for your hearing aids and told the provider you would file for reimbursement.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. There is no coverage for Hearing Aids when received from an out of network provider. The Plan states the hearing benefit is not
covered if the services are not ordered through the designated vendor. Therefore, we decided that the Plan does not have to pay for hearing aids purchased on August 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.
You asked the Plan to pre-approve this request. You say that this drug is medically necessary. The Plan denied your request. The Plan says Hyalgan step therapy criteria are not met.
We asked our physician reviewer to look at the case file. Our physician review says that this appeal considers the request for Hyalgan for the treatment of osteoarthritis in the knee. The records show the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does outline contraindications or reasons these medications were not considered. Without the support of the documentation, Hyalgan is not approved as step criteria is not met. We looked at this physician's review, the case file and the Medicare rules. Based on this information, Medicare coverage criteria for Hyalgan are not met. Therefore, the Plan is not required to provide the enrollee with coverage for Hyalagan.