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

We decided that the Plan does not have to pre-approve OneTouch Verio diabetic test strips.You asked the Plan to pre-approvethe OneTouch Verio strips. You say that this brand is necessary for the enrollee.The Plan denied your request. The Plan says there is no evidence that the use of a preferred brand of glucose meter and test strips would not be medically appropriate for the enrollee. Without a clear reason as to why the non-preferred brand is medically necessary, the request is correctly denied.The Plan must follow Medicare rules. Medicare rules say that plans are allowed to restrict coverage of DME to certain brands as long as all medically necessary brands are available. There is no documentation to support that the non-preferred brand being requested is medically necessary. There is no evidence that use of the preferred brand would be detrimental to the enrollee's health.Therefore, we decided that the Plan does not have to pre-approveOneTouch Verio diabetic test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehydrocodone and acetaminophen tablets.You asked the Plan to pre-approvethe medications. You say that the medication is needed for pain.The Plan denied your request. The Plan says this is not covered under the enrollee's medical plan.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-approvehydrocodone and acetaminophen tablets.Benefits for the medicationsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Interstim implantation
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records strongly support that the
enrollee has bladder outlet obstruction due to the pubovaginal sling, and an Interstim is not indicated for this
condition. There is documentation of large post-void resudial, no detrusor instability on urodynamics, and
failure of multiple anticholinergic medications to support bladder outlet obstruction. The Insterstim is therefore
not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an Interstim implantation
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthoses, the knee orthosis and suspension sleeve, provided on September 2, 2019.
You asked the Plan to pay for the ankle foot orthoses (L1971), the knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the enrollee's current orthoses are still under reasonable useful lifetime.
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 the enrollee had an ankle foot orthoses, knee orthosis and suspension sleeve, at the time the ankle foot orthoses (L1971), the knee orthosis (L1851)and suspension sleeve (L2397) was received. The orthoses serve the same purpose as the ankle foot orthoses (L1971), the knee orthosis (L1851) and suspension sleeve (L2397) at issue. The documentation submitted does not show the enrollee's orthoses are worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthoses at issue. Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses, the knee orthosis and suspension sleeve, provided on September 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says there are no medical issues that require supervision by an inpatient rehab physician three times a week.
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 physician reviewer found that the enrollee's medical conditions appear stable. There is no complex wound care needs. He does not require medical oversight of his condition at an acute hospital level of care. He has a new unilateral upper extremity impairment without identified significant lower extremity impairment. The enrollee is limited by his recent fall and the severity of his comorbid medical conditions. He would not be expected to be able to fully participate in, or benefit from the required intensity of an acute rehabilitation therapy 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a hip brace and hip joint adjustable extension (L1686, L2624) provided to the enrollee on August 19, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a hip brace and hip joint adjustable extension (L1686, L2624) provided to the enrollee on August 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hip brace with extension (L1686, L2624) and knee orthoses with suspension sleeve (L1851, L2397) provided to the enrollee on August 16, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for hip brace with extension (L1686, L2624) and knee orthoses with suspension sleeve (L1851, L2397) provided to the enrollee on August 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says the
enrollee does not meet Medicare criteria for SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says
that daily skilled services are not medically necessary. Our physician reviewer found the enrollee has a past
medical history of TIA, COPD, a heart murmur, and spinal fusion. She was admitted to the hospital on
February 11, 2020 due to combativeness. The enrollee was alert and oriented at the time of admission. She had
no specific complaints. The enrollee ambulated 20ft x 2 on February 16, 2020. Sit to stand required MinA,
CGA was needed for stand to sit, and transfers. Our physician reviewer found that the specialized skill,
knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide
medically necessary and reasonable treatment. Although there are identifiable skilled therapy service needs,
skilled nursing or skilled therapy services (or a combination of these services) was not medically necessary on
a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an
inpatient basis in a skilled nursing facility setting. The enrollee does not meet severity of illness or intensity of
service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve an admission for skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services to be provided.
You asked the Plan to pre-approve the SNF services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says the enrollee's needs could be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services to be provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the lumbar spine for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says there is no narrative of the pain history, and no description of the pain, modifying factors, and past treatments.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the requesting physician has asked prior facility for records concerning previous workup and treatment but these are not included in the submitted records. There is a brief cursory physical exam and there are no red flags to mandate MRI at this time without a trial of conservative management. Also, the requesting physician has interpreted himself the recent plain films of the lumbar spine but there is no description of his impression in the records. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the lumbar spine for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a DME
You asked the Plan to pre-approve a power operated vehicle. You say that you have a power wheelchair but
want a scooter for use outside of your home. The Plan denied your request. The Plan says the Raptor Three
Wheeled Scooter is not a Medicare approved power mobility device.
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 power wheelchair. Your power wheelchair serves the same purpose as a power
operated vehicle. The requested scooter does not fit in a home due to the large size and is not Medicare
approved. Medicare does not cover power operated vehicles for use only outside the home. Therefore, we
decided that the Plan does not have to pre-approve a DME
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ALS genetic testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that identifying a mutation will help guide the enrollee's treatment. The Plan denied your request. The Plan says Medicare does not cover genetic tests based on family history alone.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is interested in genetic testing to see if he carries genes which might put him at increased risk of developing several neuromuscular disorders. Such testing is not diagnostic and is for informational purposes only. The documentation does not support that the requested testing is medically necessary or reasonable to diagnose, treat or otherwise manage the enrollee's health.
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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve ALS genetic testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services provided on February 2, 2019 through August 31, 2019.You asked the Plan to pay for the dialysis services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the claim does not have a D5 Value Code with amount nor does it have the 51 Occurrence Code with the date.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code  is not supported in the record. Specifically, the claim does not include the required Value D5 and Occurrence 51 codes. Based on this information, we decided that Medicare rules for coverage of the dialysis services have not been met.Therefore, we decided that the Plan does not have to pay for dialysis services provided on February 2, 2019 through August 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the walker, shower chair, and sock slider purchased on April 26, 2018.You asked the Plan to reimburse you forthe walker, shower chair, and sock slider. You say that you really need these items.The Plan denied your request. The Plan says your claims are untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the walker, shower chair, and sock slider was not filed until October 1, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to reimburse you forthe walker, shower chair, and sock slider purchased on April 26, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive they copayment for the ambulance transport provided on September 29, 2019.You asked the Plan to waive they copayment for the ambulance transport. The Plan denied your request. The Plan says that the claim processed 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 a $265 copayment for ground ambulance services. You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the ground ambulance 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 they copayment for the ambulance transport provided on September 29, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHyalgan.You asked the Plan to pre-approveHyalgan. You say that the requested Hyalgan is medically necessary.The Plan denied your request. The Plansays the enrollee must try and fail Orthovisc and Monovisc first.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 Hyalgan. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of bilateral primary osteoarthritis of the knees. The Plan requires a trial of drugs Orthovisc and Monovisc first before they will approve the requested drug, Hyalgan. Based on the documentation provided, the enrollee has not tried and failed the required drugs. The documentation does not support that Monovisc and Orthovisc would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Hyalgan have not been met.Therefore, we decided that the Plan does not have to pre-approveHyalgan.
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 are a stroke victim and are at high risk of falling and need this level of care as you cannot be home by yourself. The Plan denied your request. The Plan says your condition is not medically complex or requiring an intensive medical team and rehabilitation doctor three times a week for 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 admitted on 1/9/2020 with intermittent hypoxia beginning 2 weeks before and a rapidly worsening course over the past few days noted by her home health nurse. She was admitted for acute hypoxic respiratory failure. She was started on antibiotics, inhalers, oxygen, and steroids. The member's medical conditions appear stable. There are no wound care needs. She does not require medical oversight of her condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, she does not require an intensive therapy program. The member is limited by debility and the severity of her comorbid medical conditions. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy 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 acute inpatient rehabilitation facility (IRF) admission and services.