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

We decided that the Plan does not have to pay the in network rate forthe drugs and medicaments (D9630) provided on September 23, 2019.You asked the Plan to pay the in network rate forthe drugs and medicaments. You say that the services you received were an immediate need as the pain was excessive.The Plan denied your request. The Plan says the drugs and medicaments you received are not a covered service.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 drug and medicaments that you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay the in network rate forthe drugs and medicaments (D9630) provided on September 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 2/2/20 status post a fall on left side, left elbow, and felt immediate groin pain, and was unable to get up from floor and called an ambulance. The enrollee was found to have right intertrochanteric femur fracture, was medically cleared for open reduction internal fixation (ORIF) on 2/3/20. Now, the hospitalcourse has included pain control. The enrollee is weight bearing as tolerated. Minimal assist is needed for basic mobility and transfers, and activities of daily living (lower body) are warranting maximum assist. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly minimum/maximum assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflx Superion Indirect Decompression System (22869 and 22870).You asked the Plan to pre-approvea Vertiflx Superion Indirect Decompression System (22869 and 22870). You say that the requested Vertiflex system is medically necessary.The Plan denied your request. The Plan says the requested Vertiflex system 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 a Vertiflx Superion Indirect Decompression System (22869 and 22870). Our reviewer says that the requested Vertiflex system is not medically necessary. Our physician reviewer found the enrollee has chronic low back pain with spinal stenosis, degenerative disc changes and scoliosis. She has scoliosis with a Cobb angle of greater than 10 degrees. She has had epidural steroid and facet injections. She has tried conservative therapy including Physical Therapy and a Home exercise program. She takes Norco for pain. The request is for 2 levels of interspinous spacer placement. This is still considered an investigational experimental procedure that has not had a true prospective randomized trial against the gold standard of open decompression. The enrollee also has scoliosis with a Cobb angle of greater than 10 degrees which is a contra-indication to the procedure. The requested procedure is not medically reasonable or 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 a Vertiflx Superion Indirect Decompression System (22869 and 22870) have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflx Superion Indirect Decompression System (22869 and 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forophthalmology services (92014) provided August 26, 2019. You asked the Plan to waive the copayment forthe ophthalmology services. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost sharing was applied.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. We looked at the file and the Plan's rules. The services provided were not billed as a glaucoma screening or diabetic retinal exam. The $30 copayment was correctly applied according to the 2019 Evidence of Coverage. Therefore, we decided that the Plan does not have to waive the copayment forophthalmology services (92014) provided on August 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 pre-approve admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee had a fall with a right hip fracture and then went to a SNF. She was transferred to long term care in mid-December 2019. The facility is now seeking transfer to a SNF. The enrollee's prior level of function was independent in activities of daily living. The enrollee lived in a first floor apartment with others. On 1/3/20 occupational therapy (OT) notes she had a prior left humeral fracture but is weight-bearing as tolerated for right lower extremity and left upper extremity. She is set up assist for hygiene, minimal assist for bathing, contact guard assist for toileting, set up for upper body dressing and minimal assist for lower body dressing. She is independent with bed mobility and supervised assist for transfer. The enrollee ambulated 150 feet with a wheeled walker. She is independent in wheelchair mobility, minimal assist for 4 steps with bilateral rails. The enrollee was discharged on 1/3/20 from therapy. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a
skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, complex wound care or other SNF level skilled nursing need. This enrollee's functional status does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on 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 admission to a skilled nursing facility (SNF) have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee's functional level does not require this on an intensive rehabilitation facility therapy program level 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 24, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you believe that the enrollee needs care in the IRF setting for proper recovery.The Plan denied your request. The Plan says there are no complex needs which require a hospital level of care nor a need for intensive 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 member is status-post above-knee amputation without immediate postoperative prosthesis fitting. The member's medical conditions appear stable. There are no complex wound care needs. He does not require medical oversight of his condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. There are limited goals of bed mobility and transfers with mobility at a wheelchair level at a supervision level of function or higher. He has a new unilateral lower extremity impairment without identified significant upper extremity impairment and does not require the intensity of an acute level rehabilitation therapy program. The member is limited by debility and the severity of his comorbid medical conditions. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 1/26/20 after presenting to the emergency department with noted confusion, complaints of vomiting and diarrhea for 1 week. The hospital course was complicated by a code blue 1/27/2020; cardiac arrest was due to respiratory failure. The enrollee now requires a modified diet, and is moderate/maximum assist for all care. The enrollee is hemodynamically stable. Endurance for activities is poor. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, skin and nutritional care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly moderate to maximum assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye exam provided on June 19, 2019.You asked the Plan to pay forthe eye exam and eyewear. You say that the Plan should pay for your eye exam and eyewear.The Plan denied your request. The Plan says the eyewear was purchased from an out-of-network provider and you should submit your claim to your supplemental plan.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 eyewear at a 40% discount if provided by an in network facility.We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye exam and eyewear have not been met.Therefore, we decided that the Plan does not have to pay forthe eye exam provided on June 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendovenous ablation therapy (36475).You asked the Plan to pre-approveendovenous ablation therapy (36475). You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested procedure.The Plan must follow Medicare rules. Medicare rules say that treatment for symptomatic chronic venous insufficiency or varicose veins may be covered as medically necessary with the above criteria.We looked at the file and Medicare rules. The file shows that you do not have a BMI of 35 or less. Based on this information, we decided that Medicare rules for coverage of endovenous ablation therapy (36475) have not been met.Therefore, we decided that the Plan does not have to pre-approveendovenous ablation therapy (36475).
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for abdominal pain following recent gastric bypass surgery. An exploratory surgery revealed no anatomic pathology in the enrollee's abdomen. The enrollee was intubated for the surgery and subsequently received a tracheotomy. The enrollee has remained on a ventilator. It is unclear if the enrollee can currently be fully liberated from the ventilator or if she should be decannulated. She appears to be at high risk for recurrent respiratory issues and in need of ongoing respiratory support. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveDupixent injectors.You asked the Planto pre-approvethe Dupixent. You say that this is needed.The Plandenied your request. The Plansaysthis self-injected drug is not covered by Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveDupixent injectors.Benefits forthe Dupixentmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrolle had a cerebral vascular accident (CVA) in the fall of 2019 that left him with left hemiplegia and dysphagia. He had skilled nursing facility services and home health care services and his physician feels he needs more aggressive therapy. The enrollee uses a wheelchair for ambulation. The enrollee is able to feed himself andneeds supervision for grooming. He has a left hand immobilizer with left elbow contracture. Swallow study on 11/22/19 recommends soft foods. The enrollee wants IRF to improve stamina.The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee's functional level does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.