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

We decided that the Plan does not have to pre-approveadditional routine transportation trips (A0100).You asked the Plan to pre-approveadditional routine transportation trips. You say that the requested additional transportation is necessary for the enrollee to get to dialysis treatments.The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria has not been met.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 50 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation trips (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurolysis of the genicular (knee) nerves.
You asked the Plan to pre-approve the nerve procedure. You say that this would be beneficial as other treatments have not helped to treat your condition. The Plan denied your request. The Plan says this is an experimental procedure that cannot be covered.
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 nerve procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has knee pain from osteoarthritis. He has tried over the counter drugs, steroid injections, and viscosupplementation without sustained relief. Diagnostic knee nerve blocks were tried with excellent pain relief and neurolysis is requesting for extended relief. This is an experimental/investigational procedure that is the subject of ongoing clinical trials. The patient is not enrolled in a clinical trial. The request is therefore, considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nerve procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve neurolysis of the genicular (knee) nerves.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a polysomnogram (PSG) with continuous positive airway pressure (CPAP) titration.You asked the Plan to pre-approve the PSG with CPAP titration. You say that this enrollee is scheduled for a PSG in July with a PSG with CPAP to follow, if the first test is positive. These should be approved due to the enrollee's symptoms.The Plan denied your request. The Plan says the first PSG has been approved; however, approval cannot be granted with the CPAP titration study until the diagnosis of sleep apnea is confirmed.The Plan must follow Medicare rules. Medicare rules say that only services that are medically necessary to diagnose or treat a condition are covered.In this case, the results of the approved PSG are needed in order to determine whether the CPAP titration study is needed.Therefore, we decided that the Plan does not have to pre-approve a polysomnogram (PSG) with continuous positive airway pressure (CPAP) titration.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on December 6, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you had a pic line removed and disagree with the additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency care 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 an ER visit provided on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that you require the device and
cannot afford it. The Plan denied your request. The Plan says the documentation did not support the 4-week
trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device
(E0652).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says under Medicare guidelines, the request is not medically necessary the records show that custodial services are being requested.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the documentation does not indicate that you currently have a skilled therapy or skilled nursing need therefore the request does not meet the criteria for home health aide services. Home health aide services are not reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. 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 home health services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveopen magnetic resonance imaging (MRI) services with an out-of-network provider.You asked the Plan to pre-approvethe open MRI services. You say that you feel an open MRI is a safer option due to the pandemic. You say that the provider who supplies the open MRI is also a free standing facility with limited hours. You say that the in-network MRI is provided in a hospital, which is not a safe place for you.The Plan denied your request. The Plan says there is no medical evidence available that demonstrates the risk of contracting COVID-19 is increased with conventional MRI versus an open MRI.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 open MRI services. Our reviewer says that an open MRI is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has pain in the right shoulder andother chronic pain. There is a concern for structural abnormality in the right shoulder, and an MRI without contrast has been advised prior to any interventional procedure. The medical documentation in the case file does not support that an open MRI is medically reasonable and necessary for the enrollee. The in-network standard MRI being offered by the plan is sufficient for treatment of the enrollee, based on the records provided.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 open MRI services have not been met.Therefore, we decided that the Plan does not have to pre-approveopen magnetic resonance imaging (MRI) services with an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 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 there is no documentation showing that the step criteria guidelines were followed.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the case file doe snot contain documentation of trial and failure of zoledronic acid. The documentation does not support that zoledronic acid would likely be less effective and/or would likely have adverse affects 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMCT Oil and MCT ProCal.You asked the Plan to pre-approveoral nutritional products. You say that because of medical conditions the enrollee needs oral nutritional products.The Plan denied your request. The Plan says enteral nutrition for oral intake is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.The items you asked the Plan to pre-approve are nutritional supplements.Therefore, we decided that the Plan does not have to pre-approveMCT Oil and MCT ProCal.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram provided on January 8, 2020.
You asked the Plan to waive the copayment for the mammogram. You say that you had a preventive mammogram on your healthy right breast. You say there should be no additional cost. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $50 copayment for each in-network covered x-ray service, including diagnostic mammogram. You have been asked to pay a $50 copayment for the mammogram. The mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows a diagnosis of a personal history of malignant neoplasm which makes the mammogram diagnostic in nature.
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 mammogram provided on January 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stabilized and ready to
transfer. The Plan denied your request. The Plan says the enrollee needs to compete their full course of care in
the hospital.
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 physician
reviewer found that the enrollee presented to the acute hospital with a left femur fracture after a fall in her
home. She was treated in hospital with surgical repair of the fracture. Post-operatively she suffered pneumonia
with evidence of aspiration on swallow evaluation. A percutaneous feeding tube was placed. She was treated
with intravenous antibiotics and nebulizers for the pneumonia; she is on nasal cannula oxygen. She is very
weak, does not respond to questions, and does not follow commands. The acute care hospital is able to provide
all of the services the enrollee requires. The enrollee is receiving necessary services and is at an appropriate
level of care in the acute care hospital. Therefore, the requested LTACH services are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat elevation feature and attendant control.You asked the Plan to pre-approvethe requested items. The Plan denied your request. The Plan says the requested services are not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The file shows that a power seat elevation feature was requested. This item is not primarily medical in nature. An attendant control was requested. This item is not covered as the enrollee-operated drive control system has already been approved by the plan. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approvea seat elevation feature and attendant control.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDuloxetine.You asked the Plan to pre-approveDuloxetine. You say that the enrollee has been stable without side effects on the current treatment.The Plan denied your request. The Plan says Duloxetine to be taken at home is not covered under the Part B 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-approveDuloxetine.Benefits for Duloxetinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary.The Plan denied your request. The Plan says that you do not meet criteria for coverage of an IRF admission.The Plan must follow Medicare rules. The rules say that an 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 you do not require the intensity of services provided at an inpatient rehabilitation facility. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your needs can be met 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epifix/Epicord bioengineered skin substitute (BSS) for use on a forehead wound.
You asked the Plan to pre-approve the BSS treatments. You say that this wound has been non-healing for over a year and would benefit from the use of this treatment. The Plan denied your request. The Plan says this is only shown to be effective for diabetic ulcers or venous stasis ulcers. Use on a non-healing surgical wound is not proven.
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 BSS treatments. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have a chronic forehead wound following a MOH procedure. The enrollee has been receiving wound care and did show improvement with both a wound vac and compound medication. The enrollee is currently refusing a repeat course of treatment with a wound vac. There is no evidence that standard skin grafts have been performed. As such, the documentation does not show that the requested wound care is 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 the BSS treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve Epifix/Epicord bioengineered skin substitute (BSS) for use on a forehead wound.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs daily physician rounding, aggressive pulmonary toilet, and rehab therapy.The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a large subdural hemorrhage with herniation following several recent falls. The enrollee was intubated/ventilated and underwent surgical evacuation of the hemorrhage. The enrollee subsequently received a tracheotomy and has since been weaned from the ventilator. 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.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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
You asked the Plan to pre-approve the Prolia injections. You say that the enrollee needs this drug to treat her osteoporosis. The Plan denied your request. The Plan says there has not been a trial of oral bisphosphonates, which is required prior to this treatment.
The Plan follows Medicare rules. Medicare rules say that Prolia may be covered when other available osteoporotic therapy has been tried and failed. 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 Prolia injections. Our reviewer says that the requested use of Prolia is not considered medically reasonable and necessary at this time. Our physician reviewer found the enrollee was noted to have mild osteoporosis on a bone scan two years ago. A more recent bone scan was reportedly planned, but has not been submitted for review. The enrollee is noted to have parathyroid issues and vitamin D deficiency, for which she takes calcium and vitamin D. Recent lab results to monitor this therapy have not been submitted for review. There is no evidence that the enrollee has taken oral osteoporosis medication, resulting in treatment failure or intolerance. Therefore, the documentation does not support that the request for Prolia is currently 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 the Prolia injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower. You asked the Plan to pre-approve a walk-in shower. You say that because of your medical condition you need a walk-in shower. The Plan denied your request. The Plan says a walk-in shower is not considered to be durable medical equipment per Medicare Guidelines. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Medicare does not cover home modifications. Therefore, we decided that the Plan does not have to pre-approve a walk-in shower.