Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a two-year gym membership package for 2020 and 2021 which was purchased on December 3, 2019.
You asked the Plan to pay for the gym package in 2020 and 2021. You say that this membership was good for two years and should be covered for each year it was used. The Plan denied your request. The Plan says the date of purchase is the date of service. You paid for the two-year package for 2020 and 2021 in full on December 3, 2019. This means that the date of service for these two memberships is considered December 3, 2019. In 2019, you also had a monthly gym membership. The Plan had paid $230.25 for the membership in 2019 prior to this purchase. Therefore, you only had $9.75 left available in your $240 allowance for the year. You were paid the full allowed amount for 2019, however reimbursement cannot be provided in 2020 or 2021 because the date of purchase, and therefore date of service, was in 2019.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits for up to $240 per year. The date of service for these benefits is the date that you make payment. The Plan's rules for coverage of gym benefits have not been met because you did not make a payment for the membership package in 2020 or 2021. You paid for the package in full in 2019. The Plan provided documentation that you were provided reimbursement up to the total maximum of $240 for the 2019 Plan year. However, because payment was not made for this gym package in 2020 and 2021, it is not eligible for reimbursement for these years. Therefore, we decided that the Plan does not have to pay for a two-year gym membership package for 2020 and 2021 which was purchased on December 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc knee injection.
You asked the Plan to pre-approve Synvisc, Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg (J7325). You say that the enrollee has a partial knee replacement and would like to avoid steroid injections. The Plan denied your request. The Plan says medical studies have not proven that the viscosupplement injection is helpful for treatment of knee pain following knee replacement surgery.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc, Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg (J7325). Our reviewer says that detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures prior to injection. Our physician reviewer found imaging studies are not provided for review to demonstrate osteoarthritis of the right knee. In addition, there is an absence of significant large volume long-term support in the medical literature for this request. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to literature. Therefore Synvisc, hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection 1 mg (J7325) is not reasonable and 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 Synvisc, Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg (J7325) have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc knee injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and resin-based composite provided on January 4, 2021 by an OON provider.
You asked the Plan to pay for the first intraoral periapical x-ray and resin-based composite. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that the amounts you are being charged are correct.
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, you are responsible for the difference between the billed amount and allowed amount for the first intraoral periapical x-ray. The contract also says that you have a $100 deductible that you must pay before the Plan will pay their share of the cost for your covered dental services. After you have met your deductible, you are responsible for a 30% coinsurance for a resin-based composite. The Plan contract also says that you are responsible for the difference between the billed amount and the Plan's share for services rendered OON.

Billed Amount for Resin-Based Composite
Allowed Amount
Deductible
Difference of Billed & Allowed Amount
30% Coinsurance
Member Liability for Resin-Based Composite

$245
$137
$100
$108
$11.10
$219.10

You have been asked to pay $219.10 for the resin-based composite and $18 for the first intraoral periapical x-ray. The total amount you owe for both services is $237.10 ($219.10 + $18 = $237.10). You have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and resin-based composite provided on January 4, 2021 by an OON provider.
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 this is medically necessary for the enrollee to regain independence. The Plan denied your request. The Plan says the enrollee's needs can be met at 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that the enrollee is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services at a lower 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 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional twelve (12) PT visits.
You asked the Plan to pre-approve an additional twelve (12) PT visits. You say that the therapy was helping, and you need to be able to continue therapy. You say that you cannot walk and cannot drive. The Plan denied your request. The Plan says the Medicare guidelines for medical necessity have not been met. The member has completed in-patient rehab, out-patient rehab followed by extended home health rehab for over a year post CVA. He has reached a plateau in treatment and a new baseline. There is no medical necessity identified for continued visits.
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 an additional twelve (12) PT visits. 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 that in this case, you have had previous therapy and should be independent with a home exercise program. The additional physical therapy sessions are considered excessive and not an appropriate duration and frequency for your medical condition. 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 additional twelve (12) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional twelve (12) PT visits.
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 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. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on May 2, 2021 with a urinary tract infection and end-stage renal disease. The physical therapy note dated May 13, 2021 states he needs minimal assistance with standing up to sitting down and walking 20 feet with a walker. He does not require the intensity of services in an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyelid surgery for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary because the eyelids droop. The Plan denied your request. The Plan says the criteria for MRD1 of 2.0 mm or less is not met.
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 the procedure is not medically necessary in this case based on the functional complaints, physical exam findings, and visual field test results. The health plan has a valid argument regarding the MRD measurements that do not meet criteria. Medicare LCD criteria allow for exception to the MRD criteria when there is compelling evidence of functional disability based on history and visual field information. In this situation, it is not clear that the enrollee has loss of function related to the eyelids in spite of the relatively normal MRD on examination. The visual field tests also do not offer compelling additional evidence to override the disqualifying MRD measurements. 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 eyelid surgery for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 home health skilled nursing care visits (G0299).
You asked the Plan to pre-approve 9 home health skilled nursing care visits. You say that the requested home health services are medically necessary. The Plan denied your request. The Plan says home health skilled nursing visits are no longer 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 9 home health skilled nursing care visits. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found that you are a 71-year-old female with a medical history including a chronic pressure ulcer of the right buttocks and dysphagia requiring a feeding tube. You have been receiving home health care for wound care to the right buttocks since at least December 2020. In this case, the documentation does not support that you require skilled nursing services or skilled rehab services to provide treatment that is medically necessary. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The wound care is not of a complex nature that could not be taught to a non-skilled person. The requested home health services are 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 9 home health skilled nursing care visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 home health skilled nursing care visits (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition, endoskeletal system, above knee, flexible protective outer surface covering system (CPT code L5964) and addition to lower extremity prosthesis, user adjustable heel height (CPT Code L5990), for the enrollee.
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your request. The Plan says the items are not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the items have not been met. There is no documentation that supports that the enrollee's activity subjects him to harsh environmental situations or that the enrollee engages in any extraordinary activities that would justify the need for extra protection with a flexible outer surface covering system (L5964). No justification is given in the clinical documentation for request for extra protection with a flexible outer surface covering system (L5964). Protection of the prosthesis can be achieved with the L5705, Custom Shaped Protective Cover Above Knee that has been approved. L5964 is not medically necessary and cannot be covered. The user-adjustable heel height feature (L5990) is not covered per Medicare guidelines, as it is not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve addition, endoskeletal system, above knee, flexible protective outer surface covering system (CPT code L5964) and addition to lower extremity prosthesis, user adjustable heel height (CPT Code L5990), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on May 5, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are
available in-network.
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 to the enrollee by an out-of-network
provider on May 5, 2020.
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 your situation will get worse if you are unable to get
the correct therapies in a timely manner. The Plan denied your request. The Plan says the denial of
authorization for IRF service is correct.
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 you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require - or be able to tolerate - 15 hours per week of rehabilitative services with regular
physician evaluation. Your care needs can be met at a lower level of care such as skilled nursing facility or subacute
rehabilitation.
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: 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 stay is medically necessary. 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID 19 pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 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 this patient 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. 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 the member is a 57-year-old male with a medical history including hypertension who suffered an acute stroke and was admitted to the hospital and then an inpatient rehabilitation facility. The medical record is reviewed in its entirety. The member has stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The member no longer requires daily skilled nursing and/or skilled therapy services. He could benefit from continued intermittent services at a lower level of care. Although the member made slow progress with therapy, his functional improvement has plateaued, there is no indication that transfer to a skilled nursing facility is required. He can continue to receive skilled rehab services at the current IRF or be stepped down to a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued CPAP with humidifier use.

You asked the Plan to pre-approve continued CPAP with humidifier use. You say that the requested continued CPAP with humidifier use is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued CPAP with humidifier use.

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 continued CPAP with humidifier use. Our reviewer says that the enrollee does not meet criteria for continued CPAP with humidifier use. Our physician reviewer found CPAP with heated humidifier is considered not medically necessary. The only medical records are compliance reports, which indicate the enrollee has been unable to use the device enough to meet the minimum Medicare usage requirements of at least 4 hrs/day for at least 70% of days. There are no indications of mitigating circumstances. CPAP is ineffective if not used sufficiently.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued CPAP with humidifier use have not been met. Therefore, we decided that the Plan does not have to pre-approve continued CPAP with humidifier use.