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

We decided that the Plan does not have to pre-approve power wheelchair (PWC), group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (CPT code K0823RR).
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the documentation states that you are able to functionally ambulate (walk safely) with a cane inside 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. 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 DME. Our physician reviewer found the documentation does not support that you require a power mobility device to accomplish mobility related activity of daily living (MRADLs). Additionally, it is not clear that the PWC is being requested for mobility within the home as you use a cane for ambulation. The requested DME 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair (PWC), group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (CPT code K0823RR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve a power seat elevation system. You say that you feel this item should be covered. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-covered because it is not primarily medical in nature. We looked at the file and Medicare rules. The requested item is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies.
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 criteria for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with
insulin injections three or more times per day and does not frequently adjust insulin based on blood glucose
levels. 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 Freestyle Libre continuous glucose
monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar support recliner chair.
You asked the Plan to pre-approve these services. You say that the chair will help you move from sitting from
standing. The Plan denied your request. The Plan says the item is not covered.
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 lumbar support recliner chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit you had on December 10, 2020.
You asked the Plan to pay for the visit. You say that the provider's website is confusing, and you selected the wrong type of visit. The Plan denied your request. The Plan says you have exceeded the benefit limit for this service.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. You had a covered AWV on March 6, 2020. Therefore, we decided that the Plan does not have to pay for the annual wellness visit you had on December 10, 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 the IRF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that 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 based on the records 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injection (CPT code J7325), for the enrollee.

You asked the Plan to pre-approve the medication. You say that you are requesting this for the enrollee's thumb carpometacarpal (CMC) joint arthritis. You state given your radiological findings and symptoms, this is the best course of action to preserve function and relieve pain caused by the arthropathy at that joint. The Plan denied your request. The Plan says the safety and efficacy of Synvisc-One in locations other than the knee and for conditions other than osteoarthritis have not been established. The Plan states Synvisc and Synvisc-One are not Food and Drug Administration (FDA) approved to treat osteoarthritis of the hand.

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 the medication. Our physician reviewer found the documentation does not support that the Synvisc injection is medically reasonable and necessary for the enrollee. The documentation does not support that the Synvisc injection is safe and effective for the enrollee. There is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. Food and Drug Administration (FDA) has not approved the use of Synvisc or Synvisc-One for other osteoarthritic areas (aside from the lower extremity/knee.) Additionally, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures prior to injection. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Synvisc for thumb CMC joint arthritis (J7325) is 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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc injection (CPT code J7325), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of a catheter (36589) provided on February 12, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for removal of a catheter. You say that this was an emergency visit for a patient with end stage renal disease (ESRD) for a catheter removal. You also say that if you did not provide the services, the member would not receive dialysis treatment and the hospital bill would be more expensive. To delay treatments for obtaining an authorization is not clinically acceptable and could harm the patient. The Plan denied your request. The Plan says you are a non-contracted provider who performed services to the member without prior authorization from the Plan. The Plan also 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 removal of a catheter (36589) provided on February 12, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on April 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the chiropractic services. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on April 7, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray of spine of neck, 2 or 3 views (CPT code 72040) and the office evaluation (CPT code 99203) provided from July 17, 2020, through July 22, 2020.

You asked the Plan to pay for the services. You say that chiropractic services are covered under your plan. The Plan denied your request. The Plan says Medicare guidance says coverage for chiropractor services extends only to treatment by means of manual manipulation of the spine to correct a subluxation provided such treatment is legal in the state where performed. The Plan states all other services furnished or ordered by chiropractors are not covered. The Plan states if a chiropractor orders, takes, or interprets an x-ray or other diagnostic procedure to demonstrate a subluxation of the spine, the x-ray can be used for documentation. The Plan states there is no coverage or payment for these services or for any other diagnostic or therapeutic service ordered or furnished by the 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 x-ray of spine of neck, 2 or 3 views (CPT code 72040) and the office evaluation (CPT code 99203) provided from July 17, 2020, through July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upright walker (E0147).

You asked the Plan to pre-approve the walker. 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 walker. Our reviewer says that the requested walker is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation of inability to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand. 

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 walker have not been met. Therefore, we decided that the Plan does not have to pre-approve an upright walker (E0147).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary. The Plan denied your request. The Plan says the enrollee's needs are met in the current setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found continued care in the short-term acute care hospital is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telemedicine services provided on February 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for telemedicine services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's primary care physician did not refer 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 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 telemedicine services provided on February 24, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health physical therapy (PT) services beyond September 2, 2021.
You asked the Plan to pre-approve the continued home PT services. You say that the enrollee continues to make and lose progress due to interruptions in therapy. More home care is needed to help her recover. The Plan denied your request. The Plan says the enrollee is no longer considered homebound and also does not require this level of services going forward.
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 continued home PT services. Our reviewer says that the documentation does not support the medical necessity of ongoing therapy services. Our physician reviewer found the member is a 71-year-old female with a medical history including diabetes mellitus with multiple complications, Parkinson's disease, chronic kidney disease, and hypertension. Prior to initiation of home health services, the enrollee required minimal assistance with eating and maximal assistance with dressing, bathing, toileting and bed mobility. The most recent therapy documentation indicates the member has had fluctuations in physical endurance and has been able to transfer and accomplish mobility with modified assistance for outings to the pool for exercise. The physical therapist no longer considers the member homebound. In this case, the documentation does not support that the member requires in-home skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The documentation does not support that the member is homebound. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not medically necessary as the member is able to receive services on an outpatient basis. 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 continued home PT services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health physical therapy (PT) services beyond September 2, 2021.
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 the IRF services are medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 that based on the records provided, 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 inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services and eyewear provided on
June 5, 2018.
You asked the Plan to pay for ophthalmological services and eyewear. The Plan denied your request. The Plan says while you are a member of our Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers.
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 Plan covers these services when provided by the Plan's vision provider. We looked at the file and the Plan's rules. The file shows that the vision services were not provided by the Plans vision provider. Based on this information, we decided that the Plan's rules for coverage of ophthalmological services and eyewear have not been met. Therefore, we decided that the Plan does not have to pay for ophthalmological services and eyewear provided on June 5, 2018.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for Freestyle Libre CMG reader/sensor (CPT code K0554) provided to the
enrollee on February 22, 2021.
You asked the Plan to pay for the DME. You say that the enrollee's current primary care physician (PCP)
ordered the CGM. The Plan denied your request. The Plan says that they have contacted enrollees and found
that the provider is cold calling to the enrollee. The Plan states the enrollee receiving devices but not ordering
them.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Review of the file shows that the Plan's only argument is the provider coldcalling
the enrollee; however, there is a fax from the DME provider to the enrollee's PCP. Therefore, there was
clearly appropriate communication between this DME vendor and the enrollee's PCP. The Plans denial is not
supported. Therefore, we decided that the Plan has to pay for Freestyle Libre CMG reader/sensor (CPT code
K0554) provided to the enrollee on February 22, 2021.
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.