Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CardioMEMs HF System for the enrollee. You asked the Plan to pre-approvethese 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 enrollee has NYSHA Class III congestive heart failure with mildly reduced ejection fraction (left ventricular ejection fraction of 40 to 50 percent) requiring hospitalization. Therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medicaltherapy. The CardioMEMs is considered experimental/investigational in nature and is not reasonable or medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea CardioMEMs HF System for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for enrollee.You asked the Plan to pre-approve IRF care. 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. 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on March 13, 2020 with stroke-like symptoms and was discharged home on March 16, 2020 after the stroke work-up was negative. She has been receiving home health services for rehabilitation after multiple falls. She needs minimal assistance with activities of daily living except for transfers and toilet transfers, for which she needs maximum assistance. She is medically stable and does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an intensive therapy program 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-approveacute inpatient rehabilitation facility (IRF) admission and services for enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre sensors.
You asked the Plan to pre-approve continuous glucose monitor sensors. You say that finger stick testing is hard for the enrollee due to neuropathy. The Plan denied your request. The Plan says the enrollee does not test four or more times a day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The record shows the enrollee is testing 1.9 times a day. There is no record of frequent adjustment of the insulin treatment regimen. The criteria are not met and therefore the supply allowance is not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre sensors.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve 13 treatments of Eylea for the enrollee.
You asked the Plan to pre-approve these services. You say that The Plan denied your request. The Plan says that that this request exceeds FDA indications.
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 these services. Our reviewer says that 13 treatments of Eylea are medically reasonable and necessary for the enrollee in this case. The medical evidence shows that it is safe and effective and approved for this condition. Treatment with aflibercept or another anti-VEGF medication intravitreally is the standard of care for the patient's diagnosis. The health plan's argument that the patient was receiving medication too frequently was not valid. Injection at four to eight week intervals would be reasonable and indicated given the patient's diagnosis of active CNV with persistent thickening and pigment epithelial detachment. Furthermore, the standard of care for this mode of treatment is primarily based on the individual patient response after injections rather than a strict adherence to 8-week intervals for all patients. Our physician reviewer found that the enrollee's condition meets criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-approve 13 treatments of Eylea for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on June 4, 2019.You asked the Plan to pay forthe orthosis. 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. Thismeans 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 fora lumbar-sacral orthosis (L0650) provided to the enrollee on June 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on November 20, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on November 20, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve revision of a spinal cord stimulator.
You asked the Plan to pre-approve the procedure. 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. 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 procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not document the failure of the existing stimulator battery. More documentation is needed to show that the battery has indeed failed. Revision surgery for new stimulator battery is not justified at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve revision of a spinal cord stimulator.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance ride provided on May 30, 2019.
You asked the Plan to pay for the ambulance ride. You say that the member was not signed on to hospice until after discharge and when they were at residence. The Plan denied your request. The Plan says the Medicare hospice benefits covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The record shows proof of hospice election from May 30, 2019 to June 1, 2019. Therefore, we decided that the Plan does not have to pay for the ambulance ride provided on May 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the services. You say that this is medically necessary, as you will benefit from continued short-term rehab. The Plan denied your request. The Plan says there is no skilled care need.
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 services. 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. You do not require skilled nursing or therapy services on a daily basis. You do 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
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 the enrollee requires the device.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 withan 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 preapprovea pneumatic compression device (E0652).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on November 2, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that you could have been treated at urgent care but they were closed. You say that the copayment should be paid by insurance. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the ED visit. The ED 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 the ED visit provided on November 2, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZarxio for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of non-small cell adenocarcinoma of the lung. She has not tried and failed the plan's required drugs of Neupogen and Nivestym. The records do not show that the required drugs would be less effective or contraindicated; therefore, Zarxio is not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveZarxio for the enrollee.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee is safe at her current level of care.
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 acute care hospital (ACH) for the progression of amyotrophic lateral sclerosis (ALS). The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains on a 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. 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 LTC 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in an alternate level of care, such as in a skilled nursing facility.
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 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 require intensive IRF physician or nursing supervision. You may benefit and participate from multiple therapies such as PT and OT, however the documentation does not support that you require 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services for the enrollee.
You asked the Plan to pre-approve continued services. You say that the enrollee needs additional time to function and take care of her needs at home. The Plan denied your request. The Plan says the enrollee is covered for up to 100 days each 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 October 23, 2019 to February 27, 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 continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete coverage of a lower denture.You asked the Plan to pre-approve the denture. You say that this is necessary.The Plan denied your request. The Plan says the benefit limit is $500.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 item is subject to a benefit limitation. The plan covers dental services up to a $500 allowance each year. The records show that you have $375 of this allowance left for 2020. The plan has approved an upper denture, which will exhaust the remained of the allowance. The requested lower denture will exceed the benefit limit and therefore is not covered.Therefore, we decided that the Plan does not have to pre-approvecomplete coverage of a lower denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.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 atechnician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).