Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee does not need intensive therapy.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 does not meet criteria for IRF admission. The enrollee is medically stable with no evidence of need for supervision by a physician or acute rehabilitation nursing care. The enrollee may benefit from further physical and occupational therapy but does not require an intensive therapy program. IRF admission is not medically necessary based on the patient's 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pay forthe interpretation of the pathology testing provided on September 19, 2019 billed with codes 88305-26 and 88173-26.You asked the Planto pay forthe interpretation of the pathology testing. You say that these services were provided by the physician and should be paid.The Plandenied your request. The Plansaysthatpayment was made to the hospital laboratory for both the professional and technical components of this testing. Since this payment was made, the plan is not required to pay for these services when billed by the interpreting physician.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Although the Plan has stated that payment was already made for the professional component of this testing to the facility/laboratory, no evidence has been provided showing that the facility provided the professional component of this testing. The appealing pathologist has submitted documentation supporting that this service was rendered. Without other documentation to show that payment of the profession component to the laboratory was correctly made, we find that the denial of payment for the servicesrendered by this pathologist is not supported.Therefore, we decided that the Planhas to pay forthe interpretation of the pathology testing provided on September 19, 2019 billed with codes 88305-26 and 88173-26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0367).You asked the Plan to pre-approve the cone beam CT capture and interpretation. You say that you are supposed to have 4 teeth extracted and need this CT scan.The Plan denied your request. The Plan says this service is not covered under your benefit plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0367).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-preferred brand of test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that you have been using the non-preferred brand for years and do not want to change. The Plan denied your request. The Plan says there is no medical reason documented that you are medically unable to use the Plan preferred test strips.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the non-preferred brand of test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller (E2377) harness (E2313) and
electronic connection (E2311) power seat elevation system (E2300) Quantum Height Adjustable Joystick
Mount (K0108) and quantum footplate with extension (K0108).
You asked the Plan to pre-approve the wheelchair accessories. You say that the medical documentation more
than substantiates the need for the recline feature on the group 3 power wheelchair. The Plan denied your
request. The Plan says the expandable controller, harness and electrical connection are not medically necessary.
The power seat elevation system, quantum height adjustable joystick mount and quantum footplate width
extension are not medical in nature and convenience items.
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 wheelchair accessories. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the documentation does not indicate that the enrollee requires a
proportional input other than a standard proportional joystick, a non-proportional input device. The enrollee
does not need to operate 3 or more powered seating actuators through the joystick. The enrollee does not need
an expandable controller to be able to operate one or more of the following: a separate display, other electronic
devices or an attendant control. The documentation indicates the enrollee has sufficient strength, function, and
range of motion in the upper extremities to control the power features through their own individual switches
therefore the requested E2311 Electronic connection, E2377 Expandable Controller and E2313 Expandable
Controller Harness are not 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 wheelchair accessories have not been met. Therefore, we decided that the
Plan does not have to pre-approve expandable controller (E2377) harness (E2313) and electronic connection
(E2311) power seat elevation system (E2300) Quantum Height Adjustable Joystick Mount (K0108) and
quantum footplate with extension (K0108).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.
You asked the Plan to pre-approve the requested services. You say that the enrollee will benefit from the less
invasive approach. The Plan denied your request. The Plan says the device is not as effective as surgical
decompression.
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 requested services. Our physician
reviewer found that the requested device is experimental. More research is needed to show safety and efficacy.
Therefore, the requested device is not medically reasonable or necessary at this time.
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 not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadhesive foam dressings (A6212) for the enrollee.You asked the Planto pre-approvethe dressings. You say that this is medically necessary for chronic bed sores.The Plandenied your request. The Plansaysthe request was denied because it was not ordered by the PCP.The Plan must follow Medicare rules. Medicare rules say that foam dressings are covered when used on full thickness wounds with moderate to heavy exudate. 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 dressings. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review of the provided medical records the enrollee does not have full thickness wounds (stage III or IV ulcers) with moderate to heavy exudate. Based on a medical note dated 06/06/2020 the enrollee has "bilateralstage I pressure sores to bilateral buttocks, purplish in appearance, like bruise." These areas do not met criteria for use of the adhesive foam pad.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 dressings have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadhesive foam dressings (A6212) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a combination sit to stand frame/table system.You asked the Plan to pre-approve a combination sit to stand frame/table system. You say that you need a sit to stand frame/table system to get up from a chair or sitting position.The Plan denied your request. The Plan says a sit to stand device is not a Medicare covered benefit.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules.Combination sit to stand frame/table systems are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a combination sit to stand frame/table system.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approveone additional skilled nursing (SN) visit and six additional physical therapy (PT) visit to be provided in the home health setting.You asked the Plan to pre-approvethe home health services. You say that the entire requested amount should be approved for this enrollee's care.The Plan denied your request. The Plan saysafter the approved number of visits, no further home health care will be required.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the home health services. Our reviewer says that the documentation does not support that the requested home health services are medically necessary. Our physician reviewer found the requested ongoing therapy is generally not accepted as specific and effective therapy for the patient's condition. The patient has reached a functional level that no longer requires the skills of a professional therapist. Her functional level does not need the unique skills of a professional therapist to safely and effectively provide treatment. Services do not only need to be safely and effectively performed by a therapist, or under the supervision of a therapist. The patient should be able to transition to a home exercise program. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. This patient does not require ongoing skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. The patient does not have complex wound care, new enteral feedings,or other SN needs. The patient's medical conditions are chronic and stable. Her needs do not require skilled nursing level care. Skilled nursing services are not required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The request for ongoing additional SN visits is not 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 home health services have not been met.Therefore, we decided that the Plan does not have to pre-approveone additional skilled nursing (SN) visit and six additional physical therapy (PT) visit to be provided in the home health setting
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary to return to baseline. The
Plan denied your request. The Plan says there is a lack of medical necessity.
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 enrollee's
current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may
benefit from additional multiple therapies, however the enrollee's functional level which is noted to be limited
due to fatigue does not require or indicate that this therapy must be in an IRF with an intensive level program.
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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a digital breast tomosynthesis (77062) provided January 16, 2020. You asked the Plan to waive the copayment for the breast tomosynthesis. You say that the copayment should be waived since it was part of a mammogram. The Plan denied your request. The Plan says the correct copayment was applied. 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 $150 copayment for Diagnostic Radiology. You have been asked to pay a $150 copayment for the breast tomosynthesis. The breast tomosynthesis falls within the Diagnostic Radiology 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 a digital breast tomosynthesis (77062) provided January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary.The Plan denied your request. The Plan says a power wheelchair is unproven in this setting.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 the wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found there is no documentation in the provided medical records that you have a personal mobility deficit that impairs participation in mobility-related activities of daily living. There is no documentation in the provided medical records that the enrollee can safely operate a power mobility device.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 wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GamunexIntravenous Immunoglobulin (IVIG) therapy. You asked the Plan to pre-approve Gamunex Intravenous Immunoglobulin (IVIG) therapy. You say that the requested IVIG therapy is medically necessary.The Plan denied your request. The Plan says the requested IVIG therapy is 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 Gamunex Intravenous Immunoglobulin (IVIG) therapy. Our reviewer says that the requested IVIG therapy is not medically necessary. Our physician reviewer found the enrollee has a history of cranial neuropathy as a result of meningitis and has a history of chronic migraines secondary to meningitis. The enrollee does not have a covered indication for the requested Gamunex IVIG therapy. The enrollee's diagnosis of chronic meningitis and steroid induced myopathy are not ones for which the applicable LCD supports the use of IVIG. Nor is IVIG supported for use in either of these diagnoses within the product's FDA approved labeling or the Medicare accepted Compendia. There is not a body of literature that readily supports the use of IVIG for either of the enrollee's primary diagnoses. There remains a need for well-designed scientific evaluations of IVIG in the enrollee's conditions in order to make determinations on the overall safety and efficacy of the requested treatments. Consequently, it cannot be said that the use of IVIG would be reasonable and necessary in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gamunex Intravenous Immunoglobulin (IVIG) therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve Gamunex Intravenous Immunoglobulin (IVIG) therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on February 5, 2020 from an out-of-network provider.You asked the Plan to pay for the hearing aids. You say that the audiologist is in-network and the plan only pays $800 so it should not matter where the hearing aids come from.The Plan denied your request. The Plan says you utilized a provider not in the vendor 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 the hearing aids purchased on February 5, 2020 from an out-of-network provider.