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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 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. The enrollee continues to receive acute care services for which coverage has not been denied. The record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 for the enrollee.
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 need rehab. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or in the home with home health care services.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the computed tomography (CT) scan of the thorax (71250) provided December 7, 2020.

You asked the Plan to waive the cost share for CT scan of the thorax. You say that you would like this cost share waived. The Plan denied your request. The Plan says the cost share has processed correctly in this case.

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 $300 copayment for Medicare-covered diagnostic radiology services. 

You have been asked to pay $177.37 for the CT scan of the thorax which is less than the required $300 copayment. The CT scan of the thorax falls within the Medicare-covered diagnostic radiology services 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 cost share for the computed tomography (CT) scan of the thorax (71250) provided December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Volara (high frequency chest wall oscillation) device.
You asked the Plan to pre-approve a Volara device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be provided by a provider with a non-excessively high purchase price.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 the enrollee has a home nebulizer. The requested Volara device combines three separate functions at an excessive purchase price. The provider is promoting a piece of DME equipment that combines 3 separate functions for 4.5 times the cost of purchasing these components separately. Each equipment item (the high frequency chest wall oscillator, the nebulizer, and the positive pressure device) can be approved separately. Therefore, we decided that the Plan does not have to pre-approve a Volara (high frequency chest wall oscillation) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oxygen concentrator to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the oxygen concentrator. You say that you would like to appeal the denial. The Plan denied your request. The Plan says the provider is out-of-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 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 the oxygen concentrator to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve eight additional home health skilled nursing visits.
You asked the Plan to pre-approve home health services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not 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 home health services. Our reviewer says that the services are medically necessary. Our physician reviewer found the records support that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The records include a signed physician order on April 26, 2021 with regard to skilled nursing wound care and multiple nursing visit notes dated April 18, 2021 to May 1, 2021 and two office visit notes that provide extensive details regarding the wounds and their treatment plants. The skilled nursing services are therefore 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 home health services have been met. Therefore, we decided that the Plan has to pre-approve eight additional home health skilled nursing visits.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve combination sit to stand frame/table system (E0637).
You asked the Plan to pre-approve combination sit to stand frame/table system. You say that you believe this device is necessary for the enrollee for multiple other musculoskeletal and medical reasons. The Plan denied your request. The Plan says this 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 combination sit to stand frame/table system (E0637).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gammagard.
You asked the Plan to pre-approve gammagard. You say that the requested gammagard is medically necessary. The Plan denied your request. The Plan says the requested gammagard is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 gammagard. Our reviewer says that the requested gammagard is not medically necessary. Our physician reviewer found gammagard is not FDA-approved for the enrollee's diagnosis. The requested use of gammagard is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. There is not enough information provided for rationale for IVIG. There is no data to support the use of IVIG for inflammation from leptomeningeal carcinomatosis from breast cancer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gammagard have not been met. Therefore, we decided that the Plan does not have to pre-approve gammagard.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary implant/abutment supported fixed denture for edentulous arch (D6114).

You asked the Plan to pre-approve the maxillary implant/abutment supported fixed denture. You say that you would like this service to be approved for coverage. The Plan denied your request. The Plan says this service is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a maxillary implant/abutment supported fixed denture for edentulous arch (D6114).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the advanced foot and knee features for a leg prosthetic (L5845, L5850, L5981, L5848).
You asked the Plan to pay for the advanced (K3) features for the prosthesis. You say that the enrollee requires these features. The Plan denied your request. The Plan says the advanced features of the prosthesis exceed the enrollee's need.
The Plan must follow Medicare rules. Medicare rules say that to qualify for these features the enrollee must be a K3 ambulator. The documentation notes that the enrollee currently uses a wheelchair and walker, which does not support that they are a K3 ambulator. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the advanced (K3) features for the prosthesis have not been met. Therefore, we decided that the Plan does not have to pay for the advanced foot and knee features for a leg prosthetic (L5845, L5850, L5981, L5848).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS procedure.
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee needs this procedure urgently due to his worsening heart failure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no evidence that CardioMEMS improves outcomes compared to conventional medical 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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. It has not been demonstrated that CardioMEMS is established as a standard of care compared to conventional medical management and clinical monitoring. Further clinical study is needed to determine the safety and efficacy of this device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT.

You asked the Plan to pre-approve the additional PT. You say that due to your medical condition, physical therapy is very important for your health and needed at this time. The Plan denied your request. The Plan says continued PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional PT. 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 the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. The medical records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The medical documentation does not reveal evidence of deficits of the left shoulder that require additional physical therapy. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

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 additional PT have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says members must receive care from a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 orthopedic surgeon.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital on May 18, 2021 for surgery. You had an uncomplicated procedure and have been working with physical and occupational therapy. You are walking more than 80 feet with no assistive device. You are medically stable for discharge. You have no skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Meals Program benefit.
You asked the Plan to pre-approve the Meals Program benefit. You say that you were enrolled in the last round of the Meals Program and you do not understand why you would not be eligible now. The Plan denied your request. The Plan says that the medical records received confirms that the member does not meet the criteria of having depression, which is an eligibility requirement for the program. Although the member has hypertension, there also must be a secondary diagnosis of depression or anxiety to be eligible for the program.
The Plan contract offers a supplemental Meals Program benefit. The Plan has contracted with a food delivery program to offer short-term food delivery. The enrollee must have an active diagnosis of depression and diabetes or depression or anxiety and hypertension. We looked at the file and the Plan's rules. The file shows that you do not have a qualifying active diagnosis of depression and diabetes or depression or anxiety and hypertension. Based on this information, we decided that Plan's rules for coverage of the Meals Program benefit have not been met. Therefore, we decided that the Plan does not have to pre-approve the Meals Program benefit.
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. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer.
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 physician reviewer found that in this case, the enrollee was admitted due to pneumonia and acute hypoxic respiratory failure. The medical record indicates that the enrollee continues to receive acute critical care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Therefore, the requested service cannot be recommended. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lift chair/recliner.
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your request. The Plan says this 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. Therefore, we decided that the Plan does not have to pre-approve a lift chair/recliner.