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

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments.You asked the Plan to pre-approve these services. You say that this is medically necessary.The Plan denied your request. The Plan says that there is no indication in the medical record that you are capable of operating the requested power wheelchair independently.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. 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 a power wheelchair is not medically reasonable and necessary in this case. You have a personal mobility deficit that impairs participation in MRADLs. The documentation does not support that your caregivers are unable to propel a manual wheelchair. You are unable to alleviate your mobility deficit with a cane or walker due to your upper extremity weakness. The documentation does not consistently indicate you can safely operate a PMD given your dementia history, seizure disorder history, and documentation of being fearful and having delayed responses and lacking judgement to accurately and safely maneuver the power wheelchair in small and tight spaces. Our physician reviewer found that your condition does not meet Medicare criteria for a Group 3 power wheelchair and attachments.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-approve a Group 3 power wheelchair and attachments.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 physical therapy visits.
You asked the Plan to pre-approve 4 physical therapy visits. We note the Plan approved 8 visits. You say that 12 visits are medically necessary. The Plan denied your request. The Plan says while 8 visits were approved, the remaining 4 visits are not shown to be medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 4 physical therapy visits. We note the Plan approved 8 visits. Our reviewer says the plan has approved 8 occupational therapy visits to determine the response to therapy. The documentation in the case file does not demonstrate that a total of 12 visits are medically reasonable and necessary currently. A clinical update can be provided if further visits are required after the 8 visits are complete. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 physical therapy visits. We note the Plan approved 8 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies and disposable gloves.You asked the Plan to pre-approve the requested supplies. You say that the items are medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet the Medicare  criteria.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While the requested supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies and disposable gloves.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve 3 additional speech therapy visits.
You asked the Plan to pre-approve home health services. You say that you would like reconsideration because
the member has not fully realized the potential and benefit of their speech device. The Plan denied your
request. The Plan says that the Medicare guidelines for in home speech therapy are not met.
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 home health services. Our reviewer
says that the enrollee has severe intelligibility deficits, and is making slow progress with navigation and
activation of an ACC device. Our physician reviewer found it is documented that the enrollee needs to continue
skilled therapy/training.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to
pre-approve 3 additional speech therapy visits. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the second annual wellness visit provided on September 4,
2019.
You asked the Plan to pay for the second annual wellness visit. You say that you feel you should not be
responsible for this amount and you would like the Plan to reconsider your request. The Plan denied your
request. The Plan says you received a second annual wellness visit on the date of service at issue in this appeal.
The Plan says that you received an annual wellness visit that was paid for by the Plan on August 21, 2019. The
Plan says Medicare only covers one annual wellness visit once every 12 months.
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. Medicare only covers one annual wellness visit
every 12 months. The file shows you received an annual wellness visit that was paid for on August 21, 2019.
This is less than 12 months ago. Therefore, we decided that the Plan does not have to pay for the second annual
wellness visit provided on September 4, 2019.
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 would like reconsideration because the IRF admission is medically necessary.The Plan denied your request. The Plan says the records do not show that you have a need for intensive rehabilitation or complex medical conditions which require physician supervision and a multidisciplinary team for your 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 you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your needs may be met 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 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-approve7 additional months rental of a semi-electric hospital bed.You asked the Plan to pre-approve7 additional months rental of a semi-electric hospital bed. You say that the semi-electric hospital bed is medically necessary.The Plan denied your request. The Plan says they will allow 3 months rental of a semi-electric hospital bed but the additional 7 months is not medically necessary The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 7 additional months rental of a semi-electric hospital bed. Our reviewer says that the enrollee's condition does not require positioning of the body in ways not feasible in an ordinary bed. There is no evidence of a frequent need or an immediate need to change body position. The enrollee does not need a special attachment that cannot be fixed and used on an ordinary bed. A  semi-electric hospital bed is not medically necessary for this patient.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 7 additional months rental of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve7 additional months rental of a semi-electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 27, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you haven't owed a copayment for nail trimming before. You say that you only scheduled nail trimming not an office visit. 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 $15 for each Medicare-covered visit. Before you receive podiatry services, you must first obtain a referral from your PCP. You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Podiatry services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on December 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an astigmatism-correcting intraocular lens (IOL) (V2787).
You asked the Plan to pay for an astigmatism-correcting IOL. You say that you were not aware this would not be covered. The Plan denied your request. The Plan says this processed correctly.
The Plan must follow Medicare rules. Medicare rules say that , no separate payment for the IOL is made, except for a payment adjustment for specified Category 3 NTIOLs. We looked at the file and Medicare rules. The records show that the astigmatism-correcting IOL you received (SA60A1) is not listed as a covered specified Category 3 NTIOL. Based on this information, we decided that Medicare rules for coverage of an astigmatism-correcting IOL have not been met. Therefore, we decided that the Plan does not have to pay for an astigmatism-correcting intraocular lens (IOL) (V2787).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular genetic testing provided on January 17, 2020.You asked the Plan to pay for the molecular genetic testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests,with the exception of the few tests listed above, are not covered.The molecular genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the molecular genetic testing provided on January 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued SNF care provided to the enrollee from November 6, 2019 through November 15, 2019.
You asked the Plan to pay for the SNF care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay 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 pay for the SNF care. 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. The beneficiary does not require skilled nursing or therapy services on a daily basis. 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the continued SNF care provided to the enrollee from November 6, 2019 through November 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ocrelizumab injection (J2350).You asked the Plan to pre-approve the injection. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says the records do not show that the member is current with vaccines and that they have received  hepatitis B counseling.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 injection. Our reviewer says that based on the medical records provided the documentation does not support that the ocrelizumab is medically reasonable and necessary for the member. Our physician reviewer found there is no documentation of screening for hepatitis B or review of the member's immunization status.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 Plan does not have to pre-approve ocrelizumab injection (J2350).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare, as it is not primarily medical in nature.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on January 8, 2020.You asked the Plan to waive the deductible for the office visit. You say that this was just a visit to your primary care doctor. You say that the deductible is supposed to be $0.The Plan denied your request. The Plan says the deductible 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 the plan has a combined deductible amount of $198 for covered Part B services from both in-network and out-of-network providers. Until you have paid the combined deductible amount, you must pay the full cost for covered Part B services from in-network or out-of-network providers. Physician services aren't excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that the $198 combined deductible applies to office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on January 8, 2020.Therefore, we decided that the Plan does not have to waive the deductible forthe office visit provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (HCPCS Q4196) provided to the enrollee on September 3, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not support the units billed; therefore, the billed service cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the definition of HCPCS code Q4196 is "PuraPly AM, per sq cm." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation submitted does not support the units billed. We looked at this coder'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 Plan does not have to pay for physician services (HCPCS Q4196) provided to the enrollee on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMems device for the enrollee. You asked the Plan to pre-approve a CardioMems device. You say that this device is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare does not cover experimental devices. 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 CardioMems device. Our reviewer says that this device is experimental and is not covered by Medicare. Our physician reviewer said current guidelines found the efficacy of the CardioMems device is uncertain at this time and is considered investigational and/or experimental. 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 CardioMems device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMems device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pressure-reducing mattress.
You asked the Plan to pre-approve the requested mattress. You say that the enrollee does not have multiple
stage two pressure ulcers that have not responded to treatment. The Plan denied your request. The Plan says the
air mattress provides the necessary relief to stop ulcers from fully forming.
The Plan must follow Medicare rules. Medicare rules say that pressure reducing support surfaces are only
covered under certain medical indications.
We looked at the file and Medicare rules. The documentation in the case file notes the enrollee's pressure
ulcers have resolved. There is no documentation that the enrollee has ongoing, unhealed pressure ulcers, for
which the requested mattress would be covered. Based on this information, we decided that Medicare rules for
coverage of the requested mattress have not been met. Therefore, we decided that the Plan does not have to preapprove
a pressure-reducing mattress.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (CPT 95999) provided to the enrollee on November 25, 2019. You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this code is considered a bundled procedure, as the cost is included in the cost of the primary procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95999 is "Unlisted neurological or neuromuscular diagnostic procedure We asked our coding 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 testing. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the medical records provided do not include documentation of an unlisted neurological or neuromuscular diagnostic procedure being performed on November 25, 2019, therefore this service cannot be verified. The operative report indicates that Train of Four Testing was performed. Train of Four Testing is inclusive to the IONM, whether the IONM is primarily EMG based or MEP based. There is no CPT code available to use for Train of Four Monitoring, therefore it is inappropriate to use CPT 95999 for Train of Four Monitoring. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (CPT 95999) provided to the enrollee on November 25, 2019.