Persius/hicric huggingface dataset:
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 services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted 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.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomplete bilateral noninvasive physiologic studies of upper or lower extremity arteries (93923).You asked the Plan to pre-approvecomplete bilateral noninvasive physiologic studies of upper or lower extremity arteries. You say that the service is necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 complete bilateral noninvasive physiologic studies of upper or lower extremity arteries. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records the enrollee has some vascular risk and decreased dorsal pedal pulses but all other pulses "full and equal", no documented claudication symptoms and no other lower extremity findings suspicious for lower extremity arterial disease. In this circumstance the documentation does not support the medical necessity for bilateral ankle-brachial index (ABI's). Since the enrollee is asymptomatic with full pulses in every location other than dorsal pedal and already on statin therapy, treatment would likely not change regardless of results on ABI testing. The test exceeds the enrollee's medical needs 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 complete bilateral noninvasive physiologic studies of upper or lower extremity arteries have not been met.Therefore, we decided that the Plan does not have to pre-approvecomplete bilateral noninvasive physiologic studies of upper or lower extremity arteries (93923).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metformin tab 1000 ER for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to those covered under the medical benefit.
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 Metformin tab 1000 ER for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 250 units of Botox. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the request for 650 units of Botox every 12 weeks is excessive and is not an accepted standard of practice for use. 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 requested services. Our physician reviewer found that the enrollee has a history of upper limb spasticity. In treating adult patients for one or more indications, the maximum cumulative dose should not exceed 400 Units, in a 3-month interval. The Plan had previously approved 400 units every 12 weeks. Medicare's rules require that the plan follow the FDA dosing and administration guidelines. The documentation does not support that the additional 250 units of Botox is medically reasonable or necessary for the enrollee. 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 additional 250 units of Botox.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRI. You asked the Plan to pre-approve an MRI. You say that the requested MRI is medically necessary. The Plan denied your request. The Plan says that the requested MRI is not medically necessary. 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. Specifically, it is the Plan's responsibility to show that its decision to deny coverage is correct. Records from a Plan provider are considered to be within the control of the Plan. In cases where the Plan has not supplied records from a Plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a Plan's failure to obtain records that are within the Plan's control. The Plan did not provide sufficient medical records in order to determine if the enrollee meets Medicare criteria for the requested MRI. Therefore, we decided that the Plan has to pre-approve an MRI.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair with tilt-in-space for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the plan has instead approved a high strength lightweight manual wheelchair.
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. Our reviewer says that the requested wheelchair is not considered medically reasonable and necessary in this case. Our physician reviewer found the tilt-in-space feature of the wheelchair is not medically necessary, as the enrollee must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT/OT or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. The enrollee had an assessment on 3/25/20 by a DME consulting group that does not indicate a tilt in space is medically 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair with tilt-in-space for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says the therapist requested more therapy visits than recommended.
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 the visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is generally not accepted as specific and effective therapy for the enrollee's condition. The enrollee has had sufficient prior therapy approved that she should be able to transition to an independent home exercise program with the already approved therapy. Her functional deficits do not require the unique skills of a professional therapist to safely and effectively provide treatment for the 4 remaining therapy visits. Services do not only need to be safely and effectively performed by a therapist, or under the supervision of a therapist. 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 enrollee's current condition or to prevent or slow further deterioration.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services for the enrollee.You asked the Plan to pre-approve the services. You say that there has been visual observation that the enrollee is unsteady, and at risk of falling.The Plan denied your request. The Plan says a continuation of physical therapy is considered medically necessary when the member requires the skills of a physical therapist to be medically appropriate considering the patient's symptoms and diagnosis.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 the services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is generally not accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy without significant objective functional improvement and her remaining deficits do not require 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 documentation notes home exercise training has been ongoing and after 20 sessions of supervised therapy she should be able to transition to a home program. Furthermore, the documentation notes she can walk without her cane on occasion.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 enrollee's current condition or to prevent or slow further deterioration. 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 Plan does not have to pre-approve additional physical therapy services for the enrollee.
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 to safely complete activities. The Plan denied your request. The Plan says care can be safely received at 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 enrollee was medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. The enrollee may benefit from further PT and OT, but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's medical stability. The enrollee's needs may be met at lower intensity setting, such as in a SNF. 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 replacement prefabricated knee orthosis.You asked the Plan to pre-approve the orthosis. You say that the other knee brace you were sent was wrong. They sent you a long one that kept your knee straight. You need a shorter, flexible one with no hinges that you can put on like a sock.The Plan denied your request. The Plan says this request is not medically necessary. This item is a duplicate to a prefabricated knee orthosis received on 05/10/2019.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a prefabricated knee orthosis. The prefabricated knee orthosis serves the same purpose as the orthosis.Therefore, we decided that the Plan does not have to pre-approve replacement prefabricated knee orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Sensor.
You asked the Plan to pre-approve a Freestyle Libre Sensor. You say that the enrollee needs a machine to check her sugars. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested Freestyle Libre Sensor.
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 a Freestyle Libre Sensor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee has a history of diabetes, hypertension, hyperlipidemia, asthma, depression, GERD and hypothyroidism. Her diabetes is controlled with oral medications. The review has determined that the medical records provided do not meet the requirements listed in the LCD/PIM for Medicare coverage. 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 Freestyle Libre Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Sensor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider.You asked the Plan to pre-approvethese services. You say that you need a cognitive communication evaluation for driving skills after a stroke.The Plan denied your request. The Plan says the services are available from network providers.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 items/services at issue in this appeal. The Plan confirmed that the network provider is able to providethe services you need. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea referral to an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on December 13, 2019.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a diagnostic colonoscopy on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for Outpatient diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows you received a diagnostic colonoscopy on December 13, 2019. You have been asked to pay a $250 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the Outpatient diagnostic tests 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 diagnostic colonoscopy provided on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinuation of the CPAP rental.You asked the Plan to pre-approvecontinuation of the CPAP rental. You say that you were ill for two weeks and sometimes rippedthe mask off in the night.The Plan denied your request. The Plan says you have not met compliance criteria.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. The record shows you are only at 53% and 63% of usage compliance. Based on this information, we decided that Medicare rules for coverage of continuation of the CPAP rental have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinuation of the CPAP rental.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal chiropractic manipulative treatment (98943) provided on February 17, 2020.
You asked the Plan to pay for the extraspinal chiropractic manipulative treatment. You say that you would like reconsideration because you have never received a denial for chiropractic care and cannot afford more than the copayment. The Plan denied your request. The Plan says as per the EOC, only manual manipulation of the spine is covered.
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 extraspinal chiropractic manipulative treatment (98943) provided on February 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre sensors.
You asked the Plan to pre-approve continuous glucose monitor sensors. You say that the enrollee needs the sensors to better control blood sugar levels. The Plan denied your request. The Plan says the enrollee does not meet criteria.
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. The record shows the enrollee is not insulin injecting three or more times a day. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide Group 3 power wheelchair power seat elevation system, attendant control, bag hooks, or ActiveReach feature.
You asked the Plan to provide power seat elevation system, attendant control, bag hooks, and active reach feature. You say that you need a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says the power seat elevation system, bag hooks, and ActiveReach feature are not covered by Medicare and the attendant control system is not medically necessary. The Plan follows Medicare rules. Medicare rules say that The rules say that for equipment to be covered, it must primarily serve a medical purpose and the option/accessory itself is medically necessary. The file shows that you are capable of operating the power wheelchair, therefore the attendant control is not medically necessary. Power seat elevation systems are not covered by Medicare or the Plan. Bag hooks and ActiveReach features are not medical in nature. This means that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to provide Group 3 power wheelchair power seat elevation system, attendant control, bag hooks, or ActiveReach feature.