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

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on July 14, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that the use of a telecommunications system may substitute for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited number of other physician fee schedule (PFS) services. The file shows that the laboratory services at issue were ordered via telehealth. Medicare does not allow for these services to be ordered via telehealth. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on July 14, 2019.
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 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 the enrollee was medically stable with no evidence of need for supervision by PMR Physician or needs acute rehab nursing care. She may benefit from further Speech therapy but does not require an intensive therapy program. IRF admission is not medically necessary based on her current functional status and medical stability. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99213), electrical stimulation (97032), and manual manipulation of the spine (98940) provided by an out-of-network provider from August 28, 2019 to August 30, 2019.
You asked the Plan to pay for a chiropractic office visit, electrical stimulation, and manual manipulation of the spine. You say that these services should be covered. The Plan denied your request. The Plan says these services processed correctly.
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The rules also say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for out-of-network services. The office visit and electrical stimulation you received are not Medicare-covered chiropractic services. The manual manipulation of the spine is a covered benefit, but it was provided by an out-of-network provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for out-of-network services. This cost sharing is a contractual obligation that had not been met at the manual manipulation of the spine was received on August 28, 2019 to August 30, 2019. Therefore, we decided that the Plan does not have to pay for a chiropractic office visit (99213), electrical stimulation (97032), and manual manipulation of the spine (98940) provided by an out-of-network provider from August 28, 2019 to August 30, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve intravenous immune globulin (IVIG) for the enrollee.
You asked the Plan to pre-approve the requested services. You say that the enrollee has worsening idiomatic progressive neuropathy. The Plan denied your request. The Plan says that the enrollee's condition is not indicated for the requested services.
The Plan follows Medicare rules. Medicare rules say that IVIG is only covered under certain medical indications.
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 requested services. Our physician reviewer found that the enrollee has Sjorgen's syndrome with facial neuropathy. She has severe dysphagia and weight loss, with worsening idiopathic progressive neuropathy. Many types of neuropathy are associated with Sjorgen's Syndrome and it is often difficult to characterize which type a patient has and they are characterized as idiopathic. IVIG has been proven to be effective as first line treatment as they are often antibody mediated. Therefore, the service is 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 the requested services have been met. Therefore, we decided that the Plan has to pre-approve intravenous immune globulin (IVIG) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the monthly supply allowance for a continuous glucose monitor (CGM)
provided on September 2, 2019.
You asked the Plan to pay for the CGM supplies. You say that the documentation support that payment should
be made. The Plan denied your request. The Plan says that the medical records submitted upon appeal appear to
have been altered. A date has been removed from the Delivery Ticket and the change does not meet the criteria
set forth by CMS.
The Plan must follow Medicare rules. Medicare rules say that DMEPOS items may be covered when there is a
physician order and proof of delivery.
In this case, we do not find the Plan's rationale to be compelling. It is noted that a date was removed from the
delivery ticket; however, no evidence of this is apparent. The delivery ticket clearly shows a date of September
2, 2019 along with the USPS tracking number which corresponds to a delivery confirmation for an item sent
for delivery on September 2, 2019. We find no discrepancy which would preclude payment for these supplies.
Therefore, we decided that the Plan has to pay for the monthly supply allowance for a continuous glucose
monitor (CGM) provided on September 2, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. You say that you are having extreme pain in your knee. The Plan denied your request. The Plan says you have not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.
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 Synvisc-One. Our physician reviewer found that you have osteoarthritis in both knees. The plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that you have tried and failed the required drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, or would likely have adverse effects. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
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 this is medically necessary.The Plan denied your request. The Plan says your needs could be met in a different 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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. While you may benefit and participate in additional physical and occupational therapy, you do not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
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 the enrollee had a stroke and needs to continue care in rehab. The Plan denied your request. The Plan says the request for IRF admission does not meet the requirements for approval.
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 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 documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the patient's functional status does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve a power seat elevation feature. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services to be provided.
You asked the Plan to pre-approve home health services. You say that these services should be covered. The
Plan denied your request. The Plan says the requested provider does not participate in Medicare.
The Plan must follow Medicare rules. Medicare rules say that Medicare covers HHA services when the home
health agency that is providing the services to the beneficiary has in effect a valid agreement to participate in
the Medicare program.
We looked at the file and Medicare rules. The requested provider is not listed as a Medicare home health agency. Based on this information, we decided that Medicare rules for coverage of home
health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home
health services to be provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 Day Sensor.
You asked the Plan to pre-approve a FreeStyle Libre 14 Day Sensor. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested item.
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 looked at the file and Medicare rules. Therapeutic CGMs and related supplies are covered by Medicare when all of the above coverage criteria are met. In this case, the file does not show that you are insulin-treated with three or more daily injections of insulin or a Medicare-covered CSII pump. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 14 Day Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 14 Day Sensor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.
You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says this drug is not covered under Part B.
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 Ondansetron.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an aerochamber device for the enrollee.
You asked the Plan to pre-approve the requested item. You say that the enrollee is having difficulties with using her inhaler. The Plan denied your request. The Plan says the requested item is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment is only covered under certain medical indications. We looked at the file and Medicare rules. Based on the information provided, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an aerochamber device for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says it is not necessary to receive SNF level therapy when functioning at psychical baseline.
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 services. Our physician reviewer found that the enrollee is at supervision for bed mobility, and standby assistance for transfers. This enrollee 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 enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. The enrollee'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. He 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 enrollee 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B drugs provided on July 22, 2019.
You asked the Plan to waive the coinsurance for these drugs. You say that you cannot pay this at this time. The Plan denied your request. The Plan says that you are liable for 20% of the cost for Medicare Part B prescription drugs.
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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for these drugs. These drugs fall 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 for the Medicare Part B drugs provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on August 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that our physicians rendered services to this patient and should be compensated. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member was referred by an out-of-network nursing facility.
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 Plan does not have to pay for podiatry services provided on August 21, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab tests provided on July 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient lab tests. You say that you do not directly see patients. You say that the provider still chose to send the test to our lab in effort to devise the treatment plan that they felt was best for their patient. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 Plan does not have to pay for outpatient lab tests provided on July 30, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydromorphon.
You asked the Plan to pre-approve Hydromorphon. The Plan denied your request. The Plan says this medication does not fall under Part B.
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 Hydromorphon.
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. The Plan denied your request. The Plan says IRF admission is not medically necessary.
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 that 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, wound/skin and edema care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly moderate/minimal assist for functional transfers and activities of daily living, and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable period. 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.