Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).You asked the Plan to pre-approveIRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the services can be safely received in other settings, such as skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Treatment in an intensive rehab therapy program is not required. Based on the medical records provided there is concern that you would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 PWC (K0837) and accessory items (E1028) (E1020) (E2313) (E1012) (E2377) (E1002) (E2620) (E2310) (E2607).
You asked the Plan to pre-approve the Group 2 PWC and accessory items. The Plan denied your request. The Plan says medical necessity criteria have not been met for a Group 2 Power Wheelchair.
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 Group 2 PWC and accessory items. Our reviewer says that the medical records provided do not meet the requirements listed in the LCD and LCA for Medicare coverage of the Group 2 PWC (K0837) and accessory items. Our physician reviewer found the Medicare guidelines state the patient's weight should be less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class. The enrollee had a DME consultation and his weight was noted at over 300 pounds, therefore a Group 2 power wheelchair would not be the safest and most appropriate option for this enrollee and this request is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Group 2 PWC and accessory items have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 PWC (K0837) and accessory items (E1028) (E1020) (E2313) (E1012) (E2377) (E1002) (E2620) (E2310) (E2607).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Flexitouch pneumatic compression device and appliances to be provided by an out of network provider.You asked the Plan to pre-approve the pneumatic compression device and appliances. You say that this pump has research behind it that other pumps do not have.The Plan denied your request. The Plan says it is not medically necessary to go out-of-network for a pneumatic compression device.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 theitems/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-approvethe Flexitouch pneumatic compression device and appliances to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breast prosthesis mastectomy sleeve identified with code L8010.
You asked the Plan to pre-approve a breast prosthesis mastectomy sleeve. You say that because of your medical condition the compression sleeve was prescribed for you. The Plan denied your request. The Plan says a mastectomy sleeve is denied since it does not meet the definition of a prosthesis.
The Plan must follow Medicare rules. The rules say that compression stockings described by code L8010 are noncovered because they do not meet the statutory definition of a prosthesis. 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 a breast prosthesis mastectomy sleeve identified with code L8010.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure. You asked the Plan to pre-approve Ensure. The Plan denied your request. The Plan says that you do not meet criteria for coverage. The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan does not have to pre-approve Ensure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bioness L300 GO device.You asked the Plan to pre-approve the Bioness L300 GO device. You say that the enrollee's current devices no longer work and you no longer support or service the Legacy L300. Therefore, the units need to be fully replaced.The Plan denied your request. The Plan says this device is considered not reasonable and 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 Bioness L300 GO device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee has a history of a stroke. He has no history of a spinal cord injury. In that regard the use of a FES device in this enrollee would not meet the requirements set-forth by the NCD for coverage of the requested item. As such this item would not be medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Bioness L300 GO device have not been met.Therefore, we decided that the Plan does not have to pre-approve Bioness L300 GO device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee cannot be adequately cared for in a skilled nursing facility.The Plan denied your request. The Plan says the enrollee's needs are being met in the acute setting.The Plan must follow Medicare rules. The rulessay 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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially differentthan those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with ventilator management and tracheostomy care, surveillance laboratory studies, tube feeding, wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, thatare not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a device for the enrollee.
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 covered.
The Plan must follow Medicare rules. The rules say that procedure code 0379T is denied as not reasonable and
medically necessary.
We looked at the file and Medicare rules. The services at issue are a device described by code
0379T. This code is denied as not medically necessary. Therefore, we decided that the Plan does not have to
pre-approve a device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.You asked the Plan to pre-approve a wheelchair ramp. You say that the enrollee needs a wheelchair accessible entrance to the home.The Plan denied your request. The Plan says a wheelchair ramp is not primarily medical in nature.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. Medicare does not cover home modifications. Also, the item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea wheelchair ramp.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that this is the best provider. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe removal of impacted tooth on tooth #32 (D7220).You asked the Plan to pre-approvethe removal of impacted tooth on tooth #32. You say that the member had a complaint of pain from tooth #32. You say the exam clearly indicated this tooth is a soft tissue impacted 3rd molar with tissue coverage, caries and lingual rotation. The Plan denied your request. The Plan says the services are not covered benefits.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 removal of impacted tooth on tooth #32 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approvethe removal of impacted tooth on tooth #32 (D7220).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve outpatient mental health services. You say that this is the closest doctor to you.The Plan denied your request. The Plan says you are able to see in-network providers. 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 outpatient mental health 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-approvepolycarbonate lens (V2784) and anti-reflective coating (V2750).You asked the Plan to pre-approvethe special vision lenses. You say that you need the special lenses due to your condition. You are blind in one eye and this will balance your left eye.The Plan denied your request. The Plan says the requested item is not a covered benefit.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The eyewear allowance only applies to the following limited eyewear benefits: Fashion / Designer / Premier frames collections; clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any size or Rx); tinting of plastic lenses; and scratch-resistant coating.We looked at the file and the Plan's rules. the requested service isnot covered under the plan benefits. Based on this information, we decided that the Plan's rules for coverage of the special vision lenses have not been met.Therefore, we decided that the Plan does not have to pre-approvepolycarbonate lens (V2784) and anti-reflective coating (V2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a power mobility device.
You asked the Plan to provide a power mobility device. You say that the enrollee's current scooter is broken. The Plan denied your request. The Plan says the PMD request was for use only outside the home.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the enrollee does not have a mobility deficit that impairs participation in MRADLs, and the enrollee's condition can be improved by a 4-wheeled walker. This means that Medicare rules for coverage of a PMD have not been met. Also, the item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. Therefore, we decided that the Plan does not have to provide a power mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wearable mobile cardiovascular telemetry with ECG recording, concurrent computerized real time data analysis and external mobile cardiovascular telemetry with electrocardiographic recording, concurrent.

You asked the Plan to pre-approve wearable mobile cardiovascular telemetry (93228) and external mobile cardiovascular telemetry (93229). You say that the enrollee needs this telemetry. The Plan denied your request. The Plan says the enrollee does not meet criteria.

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 wearable mobile cardiovascular telemetry (93228) and External mobile cardiovascular telemetry (93229). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records the enrollee has atrial fibrillation/flutter present on a Holter monitor and ongoing intermittent palpitations after treatment with amiodarone.  In this circumstance if further evaluation for ongoing intermittent atrial fibrillation/flutter is thought to be medically necessary then a repeat 24-48 hour Holter monitor or off-line patient activated or auto-triggered event records should be sufficient to identify cardiac rhythm during symptoms. There is no documentation to indicate the enrollee is not able to effectively manage these standard monitoring devices and no indication, other than one 24-hour Holter monitor, that these have been previously obtained to evaluate the patient's condition.  Current expert consensus guidelines endorsed by several national organizations also consider patient activated event recorders and other off-line monitoring devices appropriate initial tests for evaluation of supraventricular dysrhythmias.  Continuous real-time monitoring by telemetry services is not medically necessary in this case since off-line analysis of a patient activated device, auto-triggered device or extended continuous Holter monitor should be sufficient to identify dysrhythmias without jeopardizing patient safety.  Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services is not medically necessary 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 wearable mobile cardiovascular telemetry (93228) and external mobile cardiovascular telemetry (93229) have not been met. Therefore, we decided that the Plan does not have to pre-approve wearable mobile cardiovascular telemetry with ECG recording, concurrent computerized real time data analysis and external mobile cardiovascular telemetry with electrocardiographic recording, concurrent.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker with seat attachment. You asked the Plan to pre-approve a walker with seat attachment. You say that it is difficult to get your walker down from your second level quarters. The Plan denied your request. The Plan says a second walker is not medically necessary. The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have walker. Your walker serves the same purpose as a walker with seat attachment at issue. Therefore, we decided that the Plan does not have to pre-approve a walker with seat attachment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by doctor.You asked the Plan to pre-approve the physician's services. You say that you would like to continue to see this physician because you have been seeing an improvement in your medical conditions. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by doctor
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 1, 2019 to October 16,2019.You asked the Plan to pay for the SNF services. You say that you are requesting reconsideration on the denial for coverage. You feel that it is appropriate for the plan to cover the enrollee's brief stay.The Plan denied your request. The Plan says the enrollee's needs can be met in a lower level of care with services such as supportive care in a long-term care facility.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and 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 the skilled nursing facility (SNF) services provided October 1, 2019 to October 16, 2019