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

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNFcare. You say that this is 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 thefour 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 care.Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has no identifiable skilled nursing needs. While he has skilled therapy needs, he does not need therapy on a daily basis, nor does he 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve40mg Citalopram tablets.You asked the Plan to pre-approvethe Citalopram. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this drug is not covered for the member's condition by Medicare 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 drugsrequested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve40mg Citalopram tablets.Benefits for the Citaloprammay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from December 21, 2019 through December 25, 2019.You asked the Plan to pay for SNF care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from December 21, 2019 through December 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora referral to an out-of-network orthopedic specialist.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 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 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 fora referral to an out-of-network orthopedic specialist.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services rendered on March 29, 2019 to March 30, 2019.You asked the Plan to waive the copayment for these services. You say that you should not have to pay the copayment.The Plan denied your request. The Plan says the copayment was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for each Medicare-covered ER visit.Review of the file shows that you received ER services from March 29, 2019 to March 30, 2019. You have been asked to pay a $100 copayment for these services. These services fall within the Medicare-covered ER visit. 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 emergency room (ER) services rendered on March 29, 2019 to March 30, 2019.Your complaint about the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continued rental of a home ventilator (CPT E0466).
You asked the Plan to pre-approve the continued rental of a home ventilator. You say that the enrollee is not allowed continued use of the requested device, hospital visits will increase drastically, and her quality of life will decrease. The Plan denied your request. The Plan says the information submitted fails to meet medical necessity criteria for coverage.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 continued rental of a home ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has severe COPD with pulmonary hypertension, and heart failure with preserved ejection fraction. The enrollee is on oxygen. She gets admitted repeatedly with acute respiratory failure. She had a pCO2 of 67 at the time of admission in May 2019, but this was an acute respiratory acidosis. The pCO2 improved to 35 the next day. There is no documentation of increased pCO2 when the enrollee is in a stable state. If the enrollee were to have chronic hypercapnic respiratory failure, a ventilator would not be covered by Medicare because it appears BiPAP would meet the enrollee's needs. There is no documented failure of BiPAP. A home ventilator is not considered medically 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 the continued rental of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the continued rental of a home ventilator (CPT E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a platform crutch (E0118).You asked the Plan to pre-approve the platform crutch. You say that you would like reconsideration because the member has problems walking or moving around.The Plan denied your request. The Plan says Neither Medicare nor the Plan cover platform crutches as they are not for a medical problem.The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR)Section 422.101.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the platform crutch have not been met. Specifically, this supply is not covered by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve a platform crutch (E0118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial dentures (D5213 and D5214).You asked the Plan to pre-approve the partial dentures. You say that you would like reconsideration because you lost your dentures and are unable to eat.The Plan denied your request. The Plan says your benefit provides partial or complete dentures once every 5 years.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. The Plan covers the partial dentures once every 5 years. We looked at your request, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the partial dentures have not been met. Specifically, the record indicates that you received partial dentures in 2017. Per your EOC, your denture benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approve partial dentures (D5213 and D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveunder pads and diapersYou asked the Planto pre-approveincontinence supplies. You say that this is medically necessary, as the enrollee has cognitive delays and urinary incontinence.The Plandenied your request. The Plansaysthese items are not covered because they can't be reused.The Plan covers allitems that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverageof these items.Therefore, we decided that the Plandoes not haveto pre-approveunder pads and diapers
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for amalgam -two surfaces, primary or permanent (D2150) and crown repair necessitated by restorative material failure (D2980) provided on January 23, 2020.You asked the Plan to pay for the dental services. You say that you were never notified the plan you had was discontinuing.The Plan denied your request. The Plan says there was a phone call made to you by the Plan on October 3, 2019 to discuss the Plan change and advise of the annual notice of change was being sent.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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay for amalgam -two surfaces, primary or permanent (D2150) and crown repair necessitated by restorative material failure (D2980) provided on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cryotherapy rendered from April 15, 2019 to September 4, 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 were not medically necessary. The Plan must follow Medicare rules. Medicare rules say that cryotherapy is covered when specific criteria are met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee is noted to have a series of warts for which he received cryotherapy. documentation does not note any of the warts to have been large or painful. There is no documentation that any of the warts bled, became infected or interfered with function. As such, removal of the warts is not shown to have been medically necessary or reasonable.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 pay for the cryotherapy rendered from April 15, 2019 to September 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesacroiliac (SI) joint fusion (27279).You asked the Plan to pre-approveSI joint fusion. You say that this should be covered under Medicare rules.The Plan denied your request. The Plan says coverage criteria have 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 SI joint fusion. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current medical literature supports minimally invasive SI joint fusion for patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruption. In this case, there is clinical and imaging evidence consistent with the recommended indication of degenerative sacroiliitis. However, there is plausible concern for lumbar spine pain generation given the on-going L3 radicular pain and apparent positive response to epidural injections. There is no evidence that a lumbar pain generator had been fully considered, investigated and ruled-out, noting a current request for neurosurgical referral. Therefore, the requested right SI joint fusion is not medically reasonable and 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 SI joint fusion have not been met.Therefore, we decided that the Plan does not have to pre-approvesacroiliac (SI) joint fusion (27279).
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 can be met 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 submitted medical records do not indicate that there are significant, or complex medical or 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.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH following surgery for a small bowl obstruction. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0825) and accessories (E0128 and E2361).
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are not able to use your walker. The Plan denied your request. The Plan says your living situation is not compatible with this device.
The Plan must follow Medicare rules. Medicare rules say that a power wheelchair is covered if the beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair. We looked at the file and Medicare rules. The record indicates that your home is not currently wheelchair accessible. Based on this information, we decided that Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0825) and accessories (E0128 and E2361).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.You asked the Plan to pre-approve the referral. You say that this is medically necessary.The Plan denied your request. The Plan says a network provider visit has been approved.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. 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-approve a referral to an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on February 14, 2019.You asked the Plan to waive the copayment for these services. You say that the services should have no copayment.The Plan denied your request. The Plan says the copayment was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for Medicare-covered outpatient surgery at an ambulatory surgical center or hospital outpatient facility. Review of the file shows that you received an outpatient surgical biopsy on February 14, 2019. You have been asked to pay a $275 copayment for these services. These services fall within the Medicare-covered outpatient surgery at an ambulatory surgical center or hospital outpatient facility 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 outpatient surgical services rendered on February 14, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is subject to step therapy.
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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan injection for the enrollee.