Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic physical therapy.
You asked the Plan to pre-approve the therapy. You say that you are in a lot of pain and your doctor recommended this. The Plan denied your request. The Plan says this is not medically necessary for treatment of your condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found aquatic therapy is medically necessary for individual with functional loss (decreased strength, range of motion or mobility) due to a disease, injury or surgery and when an aquatic environment is determined to be more effective or advantageous over land-based therapy. Aquatic therapy allows for exercise in a gravity-reduced, non-weight-bearing environment under the management of a physical therapist. The documentation doesn't support that you require aquatic therapy. There is no reason clearly documented that you cannot participate in the land-based physical therapy that has been authorized. 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve aquatic physical therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power tilt/recline and power elevating leg rest
upgrades for a power wheelchair (PWC).
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 a power tilt/recline and power elevating leg rests
are 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 pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the submitted records do not support
that the enrollee has a musculoskeletal condition or the presence of a cast or brace which prevents 90-degree
flexion at the knee or significant edema of the lower extremities to require an elevating leg rest. She is not at
high risk for development of pressure ulcers and does not use intermittent catheterization for bladder
management; therefore, a power seating system is not needed to manage increased tone or spasticity. The
records do not support that the requested accessories are 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 a power tilt/recline and power elevating leg rest upgrades for a power wheelchair (PWC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient mental health care from January 26, 2021, forward.
You asked the Plan to pre-approve the inpatient mental health care. You say that inpatient care is medically necessary. The Plan denied your request. The Plan says inpatient care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our reviewer says that the inpatient mental health care does not meet Medicare criteria. Our physician reviewer found based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 26, 2021, forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety as the patient awaited placement.
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 mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve the inpatient mental health care from January 26, 2021, forward.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 17 skilled nursing visits, 1 physical therapy (PT) visit,
and 2 occupational therapy (OT) visits in your home.
You asked the Plan to pre-approve the home health services. You say that the enrollee was denied her catheter
change, PT, and in home care stated was not medically needed. You say that the enrollee is very much still
dependent on the care and is not ready to leave. You say that the enrollee still has a catheter and bed sores that
are dressed in wound care daily. You say that this is very sudden and scary for the enrollee who has been under
constant care for over 5 years. The Plan denied your request. The Plan says wound care is not considered
reasonable and necessary for superficial wounds, and wound care should be re-evaluated when wounds do not
heal after 30 days. The Plan says there is no documentation that shows this. The Plan says recertification for
physical and occupational therapies requires documentation of a face-to-face encounter with the certifying
physician.
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 services. Our reviewer
says that the services are not medically necessary. Our physician reviewer found the provided documentation
does not support that the enrollee requires skilled nursing services or skilled rehab services to provide treatment
that is medically necessary. The enrollee does not require skilled nursing or rehab services to effectively
provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance
program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically
stable without any recent exacerbations of chronic medical problems or hospitalizations. The enrollee no longer
requires skilled nursing services for a healing superficial wound. The enrollee's function appears to be at her
baseline, and she has had previous in-home rehab visits during which a home exercise program should have
been established. Therefore, the reviewer found that the requested services are not medically reasonable or
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan
does not have to pre-approve 17 skilled nursing visits, 1 physical therapy (PT) visit, and 2 occupational therapy
(OT) visits in your home.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone tablets.
You asked the Plan to pre-approve Prednisone tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Prednisone tablets are not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone tablets.
Benefits for Prednisone tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960).
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that the items provided were
medically necessary for the enrollee. The Plan denied your request. The Plan says no records were provided
that show provider ever saw enrollee.
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 shoulder elbow wrist hand orthosis. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found a physical examination of the shoulder would reasonably be required to
adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The
documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in
this case, as there is insufficient documentation of a credible physical examination of the shoulder.
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 shoulder elbow wrist hand orthosis have not been met. Therefore, we
decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services provided to the enrollee from August 6,
2020, to August 11, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Current Procedural Terminology (CPT) code 99291 GC (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99291 is "critical care visit, 30-74 minutes."
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
services at issue in this case were not supported by the medical records. Our physician reviewer found the CPT
critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing
critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that
date is not continuous. The documentation indicates that Current Procedural Terminology (CPT) code 99291
GC (1 Unit) remains not supported. The documentation submitted did not support a critical care visit of 30-74
minutes was performed on the billed date of service. The documentation does not include the time spent
providing this service.
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 critical care services provided to the enrollee from August 6, 2020, to August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the low-level laser treatment, outpatient visits, and physical medicine service provided by an out of network (OON) provider.
You asked the Plan to pay for the low-level laser treatment, outpatient visits, and physical medicine service. You say that you should not be penalized for seeing an out of network provider. The Plan denied your request. The Plan says you did not receive authorization to see the out of network provider.
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 items/services at issue in this appeal. 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 low-level laser treatment, outpatient visits, and physical medicine service provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
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 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 psoriasis. He has not tried and failed the Plan's required drugs, Remicade or Inflectra and Stelara. The records do not show that the required drugs would be contraindicated or less effective; therefore, the requested Ilumya 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-approve Ilumya.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 admission 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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee was transferred to a SNF
from hospice care for hyponatremia. She has no complex wound care or skilled nursing needs. She is
independent with transfers and toileting and needs one person limited assist for activities of daily living. She
does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the
necessary services on an inpatient basis at the SNF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a total hip arthroplasty.
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated as an outpatient.
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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. Our physician reviewer found there is no clinical rationale for the requested inpatient admission. The enrollee is medically stable. The procedure is not listed on the Medicare Inpatient Only List. The record does not record show that the physician reasonably expects that the patient's necessary hospital care will span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a total hip arthroplasty.
Appeal type: Testing
Decision: Withdrawn

We decided that the Plan has to pre-approve a repeat colonoscopy.
You asked the Plan to pre-approve the colonoscopy. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary, as the same procedure was done on 6/16/20.
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 the colonoscopy. Our reviewer says that the requested colonoscopy is considered medically reasonable and necessary in this case. Our physician reviewer found at issue in this case is the adequacy of the polyp removal on 6/16/20, and whether dysplastic tissue is retained or has regrown at the polypectomy site. In addition, you are at high risk for development of metachronous and synchronous polyps. As such, short time-frame colonoscopy as requested and with optimal preparation is medically appropriate, standard of care, and meets the criteria for approval. 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 colonoscopy have been met. Therefore, we decided that the Plan has to pre-approve a repeat colonoscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on September 23, 2020.
You asked the Plan to pay for the consultation. You say that the services were not paid on your bill because
you were given incorrect information by a plan representative. You say that you called the dental plan and were
advised that it was supposed to go under Medicare Careington. The Plan denied your request. The Plan says
consultation is not listed as a covered service.
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 items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
consultation (D9310) provided on September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee's KPS score is not at least 70.
The Plan follows Medicare rules. Medicare rules say that tumor treatment field therapy is only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee has a diagnosis of glioblastoma. The records indicate he has a KPS score of 60. The rules require a KPS score of at least 70. Therefore, the coverage criteria have not been met. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) and shoulder elbow wrist hand orthosis (L3960) provided August 10, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis and shoulder elbow wrist hand orthosis. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the proof of delivery does not have a valid signature.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery. Specifically, the proof of delivery does not contain a valid signature. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) and shoulder elbow wrist hand orthosis (L3960) provided August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation services provided by a chiropractor from October 14, 2020, to October 29, 2020.
You asked the Plan to pay for chiropractic services. You say that these services have provided relief from your extreme pain, and without the electrical stimulation you would have to go back to taking pain pills. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for electrical stimulation services provided by a chiropractor from October 14, 2020, to October 29, 2020.