Persius/hicric huggingface dataset:
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 requested SNF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 that the enrollee has stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The enrollee has tolerated inpatient rehab services and continues to improve with daily skilled nursing and/or skilled therapy services. The enrollee could benefit from continued services at the current level of care. The member has made slow progress with therapy and there is no indication that transfer to a skilled nursing facility is required. The enrollee can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care when appropriate. There are no services offered at a SNF that are not offered at 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sanexas neoGen-Series Therapy.
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 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 chronic shoulder pain. The requested procedure is not evidence-based and is considered experimental/investigational in nature. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Sanexas neoGen-Series Therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the office visit (99213) provided on December 28, 2020.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment was applied correctly to the service provided.
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 $20 copayment for a specialist office visit. You have been asked to pay a $20 copayment for the telehealth specialist office visit provided. 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 adjust the copayment for the office visit (99213) provided on
December 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says prior authorization was not obtained.
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 had network providers available who could have provided 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 services provided by an out-of-network provider on October 19, 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 LTACH services are medically necessary because the enrollee requires daily physician visits, complex wound care, and intravenous antibiotics. The Plan denied your request. The Plan says the records do not show that is it medically necessary for the enrollee to be in an LTACH in place of an acute care 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is receiving acute critical care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hernia surgery.
You asked the Plan to pre-approve the surgery. You say that you are scheduled for this surgery. The Plan denied your request. The Plan says a consultation with an abdominal wall expert to discuss medical/surgical issues is more appropriate.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found plan surgeons have opined that it is not appropriate to repair at this time due to its small size, asymptomatic nature and high risk for recurrence due to your weight. The case has also been reviewed by the group's chair of surgery who concurs. The medical record does not support the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.
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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve hernia surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device.
You asked the Plan to pre-approve placement of an auricular peripheral nerve stimulation device. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says these devices are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electroacupuncture devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic testing and the MTHFR testing
provided on December 16, 2020.
You asked the Plan to pay for the GeneSight Psychotropic testing and the MTHFR testing. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
provided are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that only the multi-gene assay is covered for
GeneSight Psychotropic testing. Medicare rules also say that testing for MTHFR is only covered for enrollees
who are pregnant.
We looked at the file and Medicare rules. Review of the file does not support that the multi-gene assay for the
GeneSight Psychotropic testing was performed. Also, the physician order for the GeneSight Psychotropic
testing was not signed. The MTHFR testing is only covered for enrollees who are pregnant. The documentation
does not support that the enrollee was pregnant. Based on this information, we decided that Medicare rules for
coverage of the GeneSight Psychotropic testing and the MTHFR testing have not been met. Therefore, we
decided that the Plan does not have to pay for the GeneSight Psychotropic testing and the MTHFR testing
provided on December 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for 2 outpatient surgical services, 2 Magnetic Resonance Imaging (MRI) exams, a Computed Tomography (CT) scan, and an x-ray (71046, 70551, 70491, 72100) provided March 6, 2018 to November 30, 2020.
You asked the Plan to waive the copayments for the outpatient services. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 $300 for outpatient surgery, $225 for CT scans, $150 for MRI's and $50 for x-rays. You have been asked to pay a total of $1,175 for 2 surgical procedures ($300 each), 2 MRI's ($150 each), a CT scan ($2250) and an x-ray ($50). 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 copayments for 2 outpatient surgical services, 2 Magnetic Resonance Imaging (MRI) exams, a Computed Tomography (CT) scan, and an x-ray (71046, 70551, 70491, 72100) provided March 6, 2018 to November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Volara system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of bronchiectasis, cystic fibrosis or a neuromuscular disease.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 system. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found the Volara system is considered not medically necessary. This device combines oscillating positive airway pressure, nebulization of medication, and positive end-expiratory pressure.
There is no convincing evidence that this device is beneficial in the treatment of asthma. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Volara system.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says the SNF care is not medically necessary. The enrollee appears to have reached maximal medical improvement.
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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee has stabilized medically and has been receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF). The enrollee no longer requires daily skilled nursing and/or skilled therapy services. The enrollee could benefit from continued intermittent services at a lower level of care. Although the enrollee made slow progress with therapy, her functional improvement has plateaued and there is no indication that transfer to a skilled nursing facility is required. The enrollee can continue to receive skilled rehabilitation services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an IRF. Admission to a SNF for inpatient skilled rehabilitation services is 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.
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 48 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-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amniotic fluid injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain from sacroiliitis. The requested service is not approved for this indication. The available literature is insufficient to establish that the requested service is not experimental or investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve amniotic fluid injection for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on the criteria.
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 the enrollee remains relatively nonresponsive and confused and is unable to cooperate with skilled therapy in any meaningful way. The enrollee requires total care. The enrollee does not have any parental medication; or complex wound care. The enrollee has a new feeding tube that requires nursing care but overall, their needs are custodial in nature. The enrollee will not be able to manage their feeding tube, but a nonskilled individual can be instructed for management purposes. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377) with expandable harness (E2313) and electronic connection (E2311), and a seat elevator (E2300).
You asked the Plan to pre-approve an expandable controller with expandable harness and electronic connection, and a seat elevator. You say that the requested items are a necessity for your care. The Plan denied your request. The Plan says the requested items 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. Medicare rules also say that a power seat elevation feature is non-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 an expandable controller with expandable harness and electronic connection. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not reveal that you require other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities support that the enrollee can control any power options through their own individual switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller with expandable harness and electronic connection have not been met. A seat elevator is non-covered. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with expandable harness (E2313) and electronic connection (E2311), and a seat elevator (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services (11057) provided March 2, 2021.
You asked the Plan to pay for the podiatry services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed CPT code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 11057 is not supported in the medical record. Specifically, the records do not show that CPT code 11057 was separate and distinct from CPT code 11740. Based on this information, we decided that Medicare rules for coverage of the podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for podiatry services (11057) provided March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.
You asked the Plan to pre-approve the seat lift mechanism. You say that a seat lift mechanism is medically necessary. The Plan denied your request. The Plan says this request appears to fall outside the coverage guidelines as the patient does not have severe arthritis of the hip or knee or have severe neuromuscular disease.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section 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 pre-approve the seat lift mechanism. Our reviewer says that a seat lift mechanism is not medically necessary. Our physician reviewer found that the documentation does not reveal that you have objective evidence of severe arthritis of the hip or knee or that the enrollee has a severe neuromuscular disease.
The documentation indicates that you would benefit from a lift chair, but the documentation does not support that the requested item would be prescribed to improve or stop deterioration of your condition. The documentation does not reveal you are completely unable to stand up from a regular armchair or any chair in the home. You are ambulatory. The criteria for the requested seat lift mechanism have not been met per Medicare Local Coverage Determination (LCD) L33801, Seat Lift Mechanisms. 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 seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.