Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an enclosed walker with accessories.

You asked the Plan to pre-approve an enclosed walker with accessories. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that enclosed walkers are not covered.

 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an enclosed walker have not been met. Therefore, we decided that the Plan does not have to pre-approve an enclosed walker with accessories.

In addition, the documentation shows that the Plan spoke with your primary care physician (PCP) and that your PCP explained that a walker with armrests is not possible as it will cause hazard for you and per the PCP's recommendation, they requested the enclosed walker.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine (72148) and magnetic resonance imaging (MRI) of the cervical spine (72141).

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are medically necessary and reasonable. Our physician reviewer found that you presented to the orthopedic surgeon with three months of progressive left-sided neck pain radiating to the dorsum of the left thumb. You also reported six months of lower back pain radiating into the buttocks and posterior thighs. You are taking prescription pain medications. The physical therapy received resulted in minimal relief. The Spurling test provided was positive. The range of motion of your back was restricted. The documentation supports that the requested MRI studies are medically necessary and reasonable for the diagnosis and potential treatment.

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 magnetic resonance imaging (MRI) of the lumbar spine (72148) and magnetic resonance imaging (MRI) of the cervical spine (72141).

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 2, 2020.

You asked the Plan to pay for the services. You say that this should be paid for, as the services were medically necessary and are covered by Medicare. The Plan denied your request. The Plan says this test has not been evaluated.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MI Profile is not listed in Palmetto GBA as a test that has been evaluated and has therefore not met Medicare's criteria for being medically necessary and reasonable. The review indicates that the enrollee does not meet the criteria for this test.

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 pay for laboratory services provided to the enrollee on November 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.

You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 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 foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that this was prescribed by your doctor due to your several imbalance issues. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from
November 6, 2020, through November 14, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says ongoing SNF care 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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications and completed a course of IV antibiotics. The enrollee had stable vital signs. Regarding rehabilitation services, the beneficiary received physical therapy (PT) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a total assist level with functional mobility and required a mechanical lift for transfers. She remained non-ambulatory. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from November 6, 2020, through
November 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation with an out-of-network provider.

You asked the Plan to pre-approve the consultation. You say that you are in pain and the doctor is great at what he does. The Plan denied your request. The Plan says in-network providers are available.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the consultation with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration because you have been using support hose for years for an issue with seeping. The Plan denied your request. The Plan says Medicare does not cover the requested stockings for your condition.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on
December 11, 2020.

You asked the Plan to pay for the office visit. You say that the medical records and referral were submitted,
and the claim should be processed in a timely manner. The Plan denied your request. The Plan says this
provider is not a network provider with the Plan and the services were not approved in advance.

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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the office visit provided by an out-of-network
provider on December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device.

You asked the Plan to pre-approve a CPM. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that CPM devices are covered only if use of the device began within two days of receiving total knee replacement surgery. 

Records show that total knee replacement surgery was received on November 23, 2020. Use of a CPM device did not begin until December 1, 2020. This means that use of a CPM device did not start until more than two days had elapsed following total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. 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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are only to take one shot of insulin per day. There is a requirement for 3-4 shots per day, and monitoring blood glucose levels 4 times a day for 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in a lower level of care.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does 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 skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that the items are necessary. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says there must be evidence of insulin treatment or a Medicare-covered insulin infusion
pump.

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 monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no indication of why a glucometer could not be used. You are not taking three shots of insulin
per day.

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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-electric hospital bed, with any type of side rails, with mattress (E0260).

You asked the Plan to pre-approve the hospital bed. You say that you are currently sleeping on the couch and has COPD with difficulty breathing. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria for the requested hospital bed.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 

2. Requires attachments which can only be attached to a hospital bed; AND 

3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 

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 hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not clearly reveal that the enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed.

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 hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve semi-electric hospital bed, with any type of side rails, with mattress (E0260).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that you can safely receive the services you need in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for coronary artery bypass
grafting. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary
care can be provided in a different level of care. There is not a reasonable expectation that you will be able to
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our
physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 9, 2020, to March 31, 2020.

You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the 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 $0 copayment for days 1-20 and a $150 copayment for days 21-100 for SNF care. 

The record shows that you had a SNF stay from March 9, 2020, to April 7, 2020. You are not being charged a copayment for days 1-20 (March 9, 2020, to March 29, 2020). You are responsible to pay a $150 copayment for days 21-28 (March 30, 2020, to April 6, 2020). However, you are only being asked to pay $1,150, which is less than the total copayment amount. 

You have been asked to pay $1,150 for a SNF stay. A SNF stay falls within the SNF 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 a SNF stay provided from March 9, 2020, to March 31, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bicycle wheelchair for the enrollee.

You asked the Plan to pre-approve the wheelchair. You say that this is a bicycle for people who are in wheelchairs. The Plan denied your request. The Plan says this is not a covered benefit.

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. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a bicycle wheelchair for the enrollee.