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

We decided that the Plan does not have to pre-approve a shower chair and standing frame/table.

You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your request. The Plan says these items are 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. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a shower chair and standing frame/table.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve home infusion with Remicade (Infliximab) and related services.

You asked the Plan to pre-approve home infusion with Remicade (J1475) and related services. You say that this drug is a first choice in post-surgical patients with Crohn's disease. The Plan denied your request. The Plan says that there is no indication the enrollee has Fistulizing disease or has failed conventional therapy.

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 home infusion with Remicade (J1475). Our reviewer says that the service is medically reasonable and necessary. Our physician reviewer found the enrollee has severe fistulizing /penetrating Crohn's disease, and has required bowel resection. The advanced activity of the disease warrants post-operative initiation of aggressive biologic therapy. Based on the enrollee's overall clinical scenario, Remicade as requested (per clinical summary) is medically appropriate and 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 home infusion with Remicade (J1475) have been met. Therefore, we decided that the Plan has to pre-approve home infusion with Remicade (Infliximab) and related services.

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: 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 acute rehab can help you get home. The Plan denied your request. The Plan says that you would benefit from skilled level rehab care at a skilled nursing facility where therapy would be able to proceed at a more tolerable pace and longer duration of time.

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 a stroke and a leg infection. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator and portable gas oxygen system for the enrollee.

You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's low oxygen levels were done eight days prior to discharge, and the level remained normal until release.

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 items. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has COPD, HFpEF, and atrial fibrillation. Oxygen was started after a previous hospitalization. During the most recent hospitalization, there are no qualifying oxygenation measurements (88% or less) within 48 hours of discharge, or after discharge. Thus continued home oxygen therapy is considered not medically necessary. Overnight oximetry and/or ambulatory oximetry would help determine whether the patient would benefit from oxygen. OSA is listed as a diagnosis, and this would need to be excluded if the enrollee has nocturnal hypoxemia.

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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator and portable gas oxygen system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve physician services. You say that you would like to continue seeing this provider. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 physician services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
You asked the Plan to pre-approve the complete maxillary denture. You say that your upper denture broke. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, complete maxillary denture (D5110) is limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) on March 7, 2018 and your complete maxillary denture (D5110) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (J0585).

You asked the Plan to pre-approve Botox. You say that you would like this drug to be reconsidered because the
enrollee does not want to undergo a surgical procedure. The Plan denied your request. The Plan says though
trials evaluating the effect of intrapyloric botulinum toxin injection on gastroparesis have been reported, there
is no agreement whether botulinum toxin can effectively relieve the symptoms and improve the results of
gastric emptying study in patients with gastroparesis.

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 Botox. Our reviewer says that Botox is
not medically reasonable and necessary for the enrollee. Our physician reviewer found though trials evaluating
the effect of intrapyloric botulinum toxin injection on gastroparesis have been reported, there is no agreement
whether botulinum toxin can effectively relieve the symptoms and improve the results of gastric emptying
study in patients with gastroparesis. Our reviewer also found that the testimonial benefit of Botox injection in
some patients with gastroparesis per the provider's attestation does not equate with standard of care, product or
procedure safety, nor medical necessity or appropriateness in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve Botox (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external receiver (A9278) and disposable sensors (A9276) for a continuous glucose monitor.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the plan has no contractual obligation to cover services that are not medically necessary.
The Plan must follow Medicare rules. The rules say that HCPCS A9276 and A9278 are not covered codes. The requested services are coded in such a way that makes it statutorily not covered by Medicare. 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 an external receiver (A9278) and disposable sensors (A9276) for a continuous glucose monitor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 7, 2020, to November 10, 2020, and from November 17, 2020, to December 6, 2020.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says from November 07, 2020, to November 10, 2020, the enrollee's condition did not require daily skilled services at an inpatient SNF level of care. The Plan also says that SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.

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. The rules also say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

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 skilled nursing services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.

We looked at this physician's review, the file, and Medicare rules. The Plan has covered 100 days of SNF care. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from November 7, 2020, to November 10, 2020, and from November 17, 2020, to December 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, K0108, E2311, E2377, E2311).

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says your upper limb strength and function are adequate to control the power options using their own switches.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

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 for E2311, E2313, and E2377. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found records show that your upper extremity strength and function are adequate to operate the power options using their own 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 the accessories have not been met. Our doctor found that E2311, E2313, and E2377 are not medically reasonable or necessary. Additionally, E2300 and K0108 are not considered primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, K0108, E2311, E2377, E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (E2311, E2377, E2313) for the enrollee.

You asked the Plan to pre-approve the accessories. 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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires 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 supports that the patient 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 the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (E2311, E2377, E2313) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyperbaric oxygen therapy.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation does not support failure of conservative medical and surgical management.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the documentation does not support failure of conservative medical and surgical management for chronic osteomyelitis or a diabetic lower extremity wound. The enrollee had a recent bone culture which revealed bacteria (Kocuria kristinae). He is awaiting an infectious disease consultation for a recommendation on antibiotic 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyperbaric oxygen therapy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgical services provided on October 15, 2020.

You asked the Plan to waive the copayment for the surgical services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgery in an ambulatory surgical center on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $275 copayment for each Medicare-covered surgery at an ambulatory surgical center.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received surgical services provided in an ambulatory surgical center on October 15, 2020. You have been asked to pay a $275 copayment for the surgical services. The surgical services fall within the Outpatient surgery 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 the surgical services provided on October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan has to pre-approve semi-electric hospital bed (E0260).

You asked the Plan to pre-approve semi-electric hospital bed. You say that that this is medically necessary. The Plan denied your request. The Plan says that the record does not support the enrollee requires frequent or immediate position changes.

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 semi-electric hospital bed. Our reviewer says that the criteria for coverage of a semi-electric hospital bed have been met. Our physician reviewer found based on the enrollee's need for elevation of head of bed for sleep, debility, and immobility, the requested semi-electric hospital bed is medically reasonable and necessary to prevent complications. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of semi-electric hospital bed have been met. Therefore, we decided that the Plan has to pre-approve semi-electric hospital bed (E0260).

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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a repeat epidural steroid 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 that the criteria has not been met for a repeat procedure.

The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 injection. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found in this case, the enrollee has failed three months of anti-inflammatory therapy as well as six weeks each
of rest and physical therapy. The enrollee had an injection with limited relief. The prescriber has determined 
that a different injection approach, a high-volume caudal approach may be more beneficial. The prescriber 
has determined that a repeat injection using a different approach is warranted.

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 been met. Therefore, we decided that the Plan has to pre-approve
a repeat epidural steroid injection for the enrollee.

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.