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 records provided support the need for IRF care. The Plan denied your request. The Plan says the records do not show a need for a rehab doctor at least 3 times a week for evaluation of your functional and medial goals and progress. The Plan say that the enrollee can safely receive the services needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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 medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status requires an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intra-articular injections of Hyaluronan Sodium (Supartz).
You asked the Plan to pre-approve intra-articular injections of Hyaluronan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. The Plan follows Medicare rules. Medicare rules say that injections of Hyaluronan Sodium are only covered for certain indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve intra-articular injections of Hyaluronan. Our reviewer says that the documentation does not support that the requested injections are medically reasonable or necessary. Our physician reviewer found you have bilateral hip avascular necrosis more severe on the left and with moderate degenerative changes. Unlike for osteoarthritis of the knee, the use of viscosupplementation (such as Supartz) in the hip is not FDA approved. Hip intraarticular injection of Hyaluronate Sodium is considered investigational and as such is not medically necessary and 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 intra-articular injections of Hyaluronan have not been met. Therefore, we decided that the Plan does not have to pre-approve intra-articular injections of Hyaluronan Sodium (Supartz).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the disposable insulin pods.
You asked the Plan to pre-approve the insulin pods. You say that you need these pods or your health will be in jeopardy. The Plan denied your request. The Plan says this type of insulin delivery system is not covered by Medicare since it does not meet the definition of DME.
The Plan must follow Medicare rules. Medicare rules say that disposable insulin pods are not covered since they do not meet the definition of durable medical equipment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insulin pods have not been met. Therefore, we decided that the Plan does not have to pre-approve the disposable insulin pods.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus Test Strips.
You asked the Plan to pre-approve these services. You say that these are necessary for you. The Plan denied your request. The Plan says that you do not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers. The items at issue are Accu-Chek Aviva Plus Test Strips. Accu-Check Aviva is not a preferred provider with the Plan for diabetic supplies. LifeScan is the preferred provider. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus Test Strips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care.You asked the Plan to pre-approve continuation of SNF care. You say that the services are necessary.The Plan denied your request. The Plan says the enrollee has exhausted the covered benefit of 100 days of SNF care per benefit period.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from February 26, 2020 to June 11, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services including an oral exam, intra-oral x-rays, and procedures (D0140, D0220, D0460, D7999) provided March 25, 2020.
You asked the Plan to pay for the dental services. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says the dental services at issue are not covered benefits under your 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 pay for dental services including an oral exam, intra-oral x-rays, and procedures (D0140, D0220, D0460, D7999) provided March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories. You asked the Plan to pre-approve a Group 2 power wheelchair and accessories. You say that a Group 2 power wheelchair and accessories is medically necessary.The Plan denied your request. The Plan says the power tilt and elevating leg rests are not medically necessary.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 a Group 2 power wheelchair and accessories. Our reviewer says that the features are not medically necessary. Our physician reviewer found the documentation is conflicting on whether the enrolleeis at high risk for development of a pressure ulcer and is unable to perform a functional weight shift as the enrollee is independent with transfer bed to wheelchair and was able to walk 10 feet. The physician progress reports do not reveal a detailed neuromuscular exam of the upper extremities evaluating individual myotomal strength and function.The medical progress reports do not indicate that the enrollee utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; needs to manage increased tone or spasticity, has a lower extremity cast or lower extremity edema therefore the requests for power tilt and recline (E1007), elevating leg rests (E1012) are not needed. Furthermore, Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) are not medically necessary as there is no evidence the enrollee needs a specialty interface or control two or more of the following motors from a single interface, e.g., proportional joystick, touchpad, or nonproportional interface. There is no evidence that the enrollee needs to operate 3 or more powered seating actuators through the drive control.There is no evidence of a need for attendant control.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 Group 2 power wheelchair and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.
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/skin care, and daily therapy can be provided at a SNF. In this case, the member is mostly standby 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 reasonable, and predicted period. An IRF intensity is not warranted. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation system identified with code E2300.You asked the Plan to pre-approvea power seat elevation system. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested device is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation system identified with code E2300.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for health club membership from January 1, 2016 through January 1, 2018.You asked the Plan to pay for health club membership. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says the Plan rules have not been met.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because you submitted for reimbursement for your 2016, 2017, and 2018 Wellness Allowance after the March 31st deadline. Your EOC states, reimbursement requests must be received by the Plan by no later than March 31st of the following year. Therefore, we decided that the Plan does not have to pay for health club membership from January 1, 2016 through January 1, 2018.
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 IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 that the medical records do not indicate that there are significant, or complex medical/nursing issues that require IRF admission. The records show you need maximum assistance. The medical records do not show that you would be able to fully benefit and/or participate in an IRF level of care. Medicare coverage criteria or IRF admission are not met. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve XIAFLEX.
You asked the Plan to pre-approve XIAFLEX. You say that the requested XIAFLEX is medically necessary. The Plan denied your request. The Plan says the requested XIAFLEX is not medically necessary.
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 XIAFLEX. Our reviewer says that the requested XIAFLEX is not medically necessary. Our physician reviewer found the enrollee is with Peyronie's disease. He has received 3 cycles of 2 injections of XIAFLEX. Medical record note dated 10/8/19 states the enrollee has 35 degrees of penile curvature but no palpable plaque. XIAFLEX is the only FDA approved medication for the treatment of Peyronie's disease. Approved indication is the presence of a palpable penile plaque and at least 30 degrees of penile curvature. Both of these criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of XIAFLEX have not been met. Therefore, we decided that the Plan does not have to pre-approve XIAFLEX.
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 these services are medically necessary. The Plan
denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require
intensive physician and nursing oversight only in an IRF. You did not have significant post op complications
that require an IRF admission. You may benefit from multiple therapies such as physical and occupational
therapy but the documentation does not support that your functional status requires an intensive rehabilitation
therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare
criteria for IRF 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the chest.You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary,The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that the documentation does not support that the requested CT scan is medically reasonable or necessary. Our physician reviewer found the enrollee underwent a chest CT in June 2020, which showed a slight prominence in LUL 11 mm nodule. A PET with CT provided in June 2020 showed minimal uptake in the left upper lobe lesion, reactive versus low grade malignancy. The clinical information reviewed shows that the same test or one similar to the requested study was previously performed. Recommend follow-up chest CT was six months to further evaluate. Additional imaging prior to six months is not supported without a clear reason why it is needed. Therefore, the enrollee does not meet criteria for the requested services.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the
case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to
pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician
reviewer found based on the medical records provided daily skilled services are not required. The medical
records provided do not show that this enrollee requires daily skilled nursing and daily skilled therapy services
on an inpatient basis, in a skilled nursing facility setting. Medicare coverage criteria are not met. We looked at
this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules
for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to preapprove
skilled nursing facility (SNF) services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic breath test (91065).
You asked the Plan to pre-approve a diagnostic breath test. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says the enrollee does not have a covered indication for the
requested breath test per Medicare guidelines.
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. Medicare only covers lactose breath hydrogen tests to detect lactose
malabsorption. The case file shows you are requesting this breath test for confirmation of diagnosis of small
intestinal bacterial overgrowth or possibly microscopic colitis. Based on this information, we decided that
Medicare rules for coverage of a diagnostic breath test have not been met. Therefore, we decided that the Plan
does not have to pre-approve a diagnostic breath test (91065).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 6,
2020.
You asked the Plan to waive the copayment for the office visit. You say that this was supposed to be an annual
wellness check. You say that you shouldn't be charged for a visit. The Plan denied your request. The Plan says
the copayment 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 $10
copayment for in-network primary care doctor visits.
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you
were treated for hypercholesterolemia, hypothyroidism, and gastroesophageal reflux disease during the office
visit.
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 office visit provided on February 6, 2020.