Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide (G0156) for bathing 3 times per week.
You asked the Plan to pre-approve the home health aide. You say that the enrollee is homebound. You say that the enrollee's husband helps when he can. You say that the enrollee's husband struggles to bathe her for fear of both falling in the shower. The Plan denied your request. The Plan says there is no evidence that the enrollee is homebound. The Plan also says that the requested service is not medically necessary.
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 home health aide. Our reviewer says that home health aide is not medically necessary. Our physician reviewer found the provided documentation does not indicate enrollee's homebound status. The reviewer found that the enrollee does not have currently documented skilled nursing or skilled therapy needs. Therefore, the reviewer found that the requested home health aide services are not shown to be 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 home health aide have not been met. Specifically, you are not receiving skilled services at this time. Therefore, we decided that the Plan does not have to pre-approve a home health aide (G0156) for bathing 3 times per week.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the walking boot provided on February 11, 2021.
You asked the Plan to waive the deductible for the walking boot. You say that the cost of the walking boot should have been covered. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible that applies towards out-of-network prosthetic provider.
The walking boot you asked the Plan to waive the deductible for falls within the "Prosthetic devices and related
supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there
is a $1,000 that applies towards out-of-network prosthetic provider. This cost sharing is a contractual obligation
that had not been met at the time the walking boot was received on February 11, 2021. Therefore, we decided
that the Plan does not have to waive the deductible for the walking boot provided on February 11, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.

You asked the Plan to pre-approve the device. You say that the enrollee had a right-sided stroke on February 14, 2017, resulting in left upper extremity partial paralysis. You state the enrollee has tried and failed standard rehab techniques, including physical therapy, occupational therapy, static bracing, and Botox injections. You state this device is medically necessary. The Plan denied your request. The Plan says a review of current medical literature shows that these service(s) do not have proven benefit and are considered experimental/investigational. The Plan states they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients.

The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care.

You asked the Plan to pre-approve home health care. You say that you do not drive, and you have fallen in the past and need assistance to go to the bathroom to bathe. The Plan denied your request. The Plan says there is no physician order or Plan of Care for home health; and there is no physician certification that you are confined to your home.

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 home health care. Our physician reviewer found the health plan's denial should be upheld. You are not shown to be homebound. You do not have documented skilled nursing or skilled therapy needs. As such, home health services are not shown to be 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 home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with adjustable knee joints (L1832) provided
October 19, 2020.

You asked the Plan to pay for a knee orthosis with adjustable knee joints. You say that you would like this
claim reprocessed for medical necessity. The Plan denied your request. The Plan says the coverage criteria
were not met for the requested item.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis is subject to the criteria listed in the
Medicare rules section.

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 a knee orthosis with adjustable knee joints.
Our reviewer says that the requested item was not medically reasonable and necessary. Our physician reviewer
found the enrollee presented with significant pain in her left lower extremity from hip to knee following
revision of a right hip arthroplasty. In this case, the enrollee has not had recent injury to or a surgical procedure
on the knee. There is no documentation of knee laxity, and the case file does not contain an objective
description of joint laxity, such as varus/valgus instability or an anterior/posterior Drawer test. The criteria for
coverage were not met for the orthosis.

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 knee orthosis with adjustable knee joints have not been met. Therefore, we
decided that the Plan does not have to pay for a knee orthosis with adjustable knee joints (L1832) provided October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an adjustable bed and Tempur-Pedic mattress.

You asked the Plan to pre-approve an adjustable bed and Tempur-Pedic mattress. You say that this item is medically necessary for your condition. The Plan denied your request. The Plan says this is a non-covered service.

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. Therefore, we decided that the Plan does not have to pre-approve an adjustable bed and Tempur-Pedic mattress.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided from
November 17, 2020, through November 19, 2020.

You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

Review of the file show that you received inpatient hospital care from November 17, 2020, through November
19, 2020. You have been asked to pay 10% coinsurance of the allowed amount for inpatient hospital care. The
allowed amount is $8,233.74. The total you owe is $823.37 ($8,233.74 x 10% = $823.37). Your 2020 EOC states that enrollees must pay 10% coinsurance for each Medicare-covered inpatient hospital care stay. 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 coinsurance for inpatient hospital care provided from November 17, 2020, through November 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for photochemothearapy (CPT code 96910)
provided from January 6, 2021, through February 3, 2021, by an out-of-network provider.

You asked the Plan to waive the copayment for the services. You say that in past years your cost share for this
share was $0. The Plan denied your request. The Plan says the claims were processed accordingly with your
2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

According to your benefits, there is a $60 copayment for each radiation therapy service you receive. CPT code
96910 for photochemothearapy is a type of radiation therapy.

The cost share for this service was $60 for the 2020 and 2021 plan year. However, your previous Primary Medical Group (PMG) processed dates of service in 2020 with the wrong cost share. You are responsible for becoming familiar with your benefits and for paying your share of the cost for covered services. Therefore, the cost share applied to radiation therapy rendered on January 6, 2021, to February 3, 2021, from out-of-network provider. 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 photochemothearapy (CPT code 96910) provided from January 6, 2021, through February 3, 2021, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the enrollee's condition could benefit from SNF care. 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 in the Medicare rules section 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 there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight assay rendered on January 24, 2021.

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 pharmacogenetics testing 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 only one test may be performed per date of service; the test should be the most likely to identify the necessary alleles/variants for the drug/drugs in question. This applies to both single gene tests and multigene panels. The records do not support that the multigene panel was reasonable and medically necessary for the enrollee. 

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 GeneSight assay rendered on January 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (88104) provided on March 21, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed on a duplicate claim.

The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one previously processed and paid by the Plan. Duplicate claims are not payable. 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 pay for the services (88104) provided on March 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 irrigation sleeves per month.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that ostomy supplies beyond the standard monthly allowance are covered when 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has malignant neoplasm of the rectum, rectosigmoid junction, and anus. The documentation does not include any recent notes outlining why daily irrigation is required. The records do not support that the enrollee requires irrigation sleeves beyond the standard four per month. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 60 irrigation sleeves per month.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital admission and for a bone marrow aspirate.

You asked the Plan to pay for the inpatient hospital admission and the bone marrow aspirate. You say that the records provided support the need for an inpatient hospital admission and for the bone marrow aspirate. The Plan denied your request. The Plan says the inpatient hospital admission and the bone marrow aspirate are not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 the inpatient hospital admission and the bone marrow aspirate. Our reviewer says that the documentation does not support that the criteria for an inpatient admission are met in this case. Our reviewer also says that a bone marrow aspirate is not medically necessary. Our physician reviewer found the enrollee is medically stable and the record does not show that at the time of the request for an inpatient admission the physician reasonably expected that the enrollee's necessary hospital care would span two midnights. Our physician reviewer also found that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 

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 inpatient hospital admission and the bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital admission and for a bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for urine PCR panel testing (CPT code(s): 87798 and 87482) provided to the enrollee on September 2, 2020.

You asked the Plan to pay for the laboratory testing. You say that these codes are payable by Medicare and were denied as experimental in error. The Plan denied your request. The Plan says the PCR testing is considered unproven and not 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 pay for the laboratory testing. Our physician reviewer found the review has determined that the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. The PCR testing is considered unproven and not medically necessary. The review has determined that the medical records provided did not meet the requirements listed in the LCD for Medicare. coverage. 

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 laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for urine PCR panel testing (CPT code(s): 87798 and 87482) provided to the enrollee on September 2, 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 for the
enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and
does not require transfer to LTACH.

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. The enrollee
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee has had a complicated hospitalization and is now severely weakened as a result. The Plan denied your request. The Plan says the stay is 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 in the Medicare rules section. 

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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for altered mental status, sepsis, pneumonia, and urinary tract infection. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 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 IRF admission and services.