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

We decided that the Plan has to pre-approveaBD 3 ML Syringe with needle.You asked the Plan to pre-approvea BD 3 ML Syringe with needle. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested testosterone itself is approved by the plan; however, the requested syringe is not covered under the enrollee's Over-the-Counter benefit.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. Specifically, the Plan has not provided any documentation showing that the requested item is not covered by Medicare. The Plan only refers to the Plan's Over-The-Counter benefit and has not provided any Medicare guidelines used to make their determination.Therefore, we decided that the Plan has to pre-approvea BD 3 ML Syringe with needle.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: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Esbriet (J8499).You asked the Plan to pre-approve the Esbriet. You say that Esbriet is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says this request is not a covered benefit under Medicare Part B because Esbriet is a drug that is taken orally.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administereddrugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Esbriet (J8499). Benefits for the Esbriet may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home ventilator (E0466).You asked the Plan to pre-approvea home ventilator (E0466). You say that the requested home ventilator is medically necessary.The Plan denied your request. The Plan says the requested home ventilator does not meet criteria.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determineif the Plan was correct in denying the request to pre-approve a home ventilator (E0466). Our reviewer says that the requested home ventilator does not meet criteria. Our physician reviewer found based on the documentation provided, coverage criteria for aportable ventilator are not met. This enrollee has chronic obstructive pulmonary disease (COPD) with chronic hypoxic and hypercarbic respiratory failure. The enrollee would likely benefit from BiPAP at night. There is no evidence of BiPAP failure; the enrollee improved on BiPAP during the hospitalization in October, and there is no documentation of worsening hypoventilation or hypoxemia during sleep, when medically stable, on BiPAP and oxygen. Certain BiPAP devices are capable of providing the AVAPS-AE mode of support, if deemed necessary. Medicare does not cover a ventilator when used as a BiPAP device. A ventilator is considered 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 a home ventilator (E0466) have not been met.Therefore, we decided that the Plan does not have to pre-approvea home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora group 2 power operated scooter.You asked the Plan to pay forthe scooter. You say that this is medically necessary.The Plan denied your request. The Plan says the notes show that you weigh 125 pounds, so the requested scooter is not appropriate.The Plan mustfollow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of HCPCS K0807 is "POWER OPERATED VEHICLE, GROUP 2 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS."We find that HCPS code K0807 is not supported in the medical record. Specifically, the notes show that you weigh 125 pounds. Based on this information, we decided that Medicare rules for coverage of the scooter have not been met.Therefore, we decided that the Plan does not have to pay fora group 2 power operated scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe prosthetic services to be provided by an out of network (OON) supplier.You asked the Planto pre-approvethe OON prosthetics services. You say that you believe that you should be allowed to get this care from the OON provider.The Plandenied your request. The Plansaysthere are in-network prosthetics suppliers able to provide this service.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 fromout-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 Plandoes not haveto pre-approvethe prosthetic services to be provided by an out of network (OON) supplier.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe 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 in the case of this enrollee, recent records show dependency on mechanical ventilation, elevated white blood cell count, suggesting incomplete resolution of infection, and ongoing IV antibiotics. Although additional efforts with rehabilitation is warranted, there was no indication that these services would not be able to be offered in the current facility while ventilation weaning and antibiotic treatment is administered. The enrollee does not require services at the LTACH that are not already available and covered in the current setting. Althoughongoing inpatient care is needed, this request for transfer to a LTACH will be considered not medically necessary 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a Skilled Nursing Facility (SNF).You asked the Plan to pre-approveSNF admission. You saythat you feel like you need assistance on a daily basis.The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found although you do have skilled nursing and skilled therapy needs, these needs are not on a daily basis. You do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require dailyskilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a Skilled Nursing Facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance supplies received on October 2, 2019.You asked the Plan to pay forthe supplies. You say that this should be paid for.The Plan denied your request. The Plan says additional separate payment for these supplies is a non-covered benefit.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that the denied HCPCS codes (A0422, A0382, and A0398) is not supported in the medical record. Specifically, payment for these codes is included in the payment for the ambulance services that were already approved. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met.Therefore, we decided that the Plan does not have to pay forambulance supplies received on October 2,2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea comprehensive oral evaluation, dental implant and bone graft.You asked the Plan to pre-approvea comprehensive oral evaluation, dental implant and bone graft. You say that these services are linked to a medical condition.The Plan denied your request. The Plan says these are non-covered dental services.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvea comprehensive oral evaluation, dental implant and bone graft.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveSynvisc injections.You asked the Planto pre-approvethe Synvisc. You say that the Synvisc should be allowed.The Plandenied your request. The Plansayswithout a valid reason that the preferred drugs are not appropriate, Synvisc is not medically necessary.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Synvisc. Our reviewer says that this request is not considered medically reasonable and necessary based on step therapy rules. Ourphysician reviewer found the patient in this case has not tried and failed Monovisc or Orthovisc, according to the provided records as required by step therapy criteria. There is no indication from the records that Monovisc or Orthovisc would likely be less effective or safe for the patient. These medications are essentially therapeutically equivalent.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 Synvisc have not been met.Therefore, we decided that the Plandoes not haveto pre-approveSynvisc injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe services provided to the enrollee on September 24, 2018.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysprior authorization was not 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 rendering 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. 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 Plandoes not haveto pay forthe services provided to the enrollee on September 24, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora home rest/domiciliary visit provided to the enrollee on September 20, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthere was no valid referral for this service.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 rendering 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. 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 Plandoes not haveto pay fora home rest/domiciliary visit provided to the enrollee on September 20, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the records provided support the SNF services.The Plan denied your request. The Plan says that the guidelines for coverage have not been met. The plan says that the enrollee can continue to receive treatment in the hospital he is in.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 reviewthe case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the criteria for coverage of SNF care have been met. Our physician reviewer found the enrollee continues to receive wound care. The enrollee requires oversight of his medical conditions and medication management. The enrollee is at risk for secondary complications of immobility such as pressure ulcers and contractures. The enrollee requires either physical therapy or occupational therapy for education of his caregivers in terms of positioning and transfers after undergoing his recent surgery. The enrollee requires daily skilled nursing services for wound care and management of his new colostomy. The enrollee's condition would be expected to deteriorate with services provided on a less than daily basis. A SNF level of care is the appropriate level of care for 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Plan has to pre-approveskilled nursing facility (SNF) care.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordischarge day management services provided to the enrollee on September 19, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare guidance says once a managed care enrollee has elected hospice, all his or her Medicare benefits revert to fee-for-service, though the enrollee still remains on managed care for any additional benefits provided by his or her managed care plan, such as dental or vision coverage.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plandoes not haveto pay fordischarge day management services provided to the enrollee on September 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the enrollee needs more help before returning home. You say that the enrollee is unable to walk.The Plan denied your request. The Plan says the treatment needed can be provided in a lower level of care. The Plan says that the enrollee is not eligiblefor skilled nursing coverage because only custodial care is needed.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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not support that the enrollee needs daily physical therapy and occupational therapy. There are no noted daily skilled complex nursing needs. The enrollee is near her baseline level of function. While the enrollee may benefit from continuing physical therapy and occupational therapy, the records do not support the need for daily therapy. The enrollee's needs are custodial in nature.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 pre-approveskilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forvision services received on August 15, 2019.You asked the Plan to pay forthe services. You say that this is medically necessary.The Plan denied your request. The Plan says the requested services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear.Therefore, we decided that the Plan does not have to pay forvision services received on August 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.You asked the Planto pre-approvethe LTACH services. You say that this is needed.The Plandenied your request. The PlansaysLTACH care is no different than short term hospital care.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 Long term acute carehospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include surveillance laboratorystudies, sacral wound care, tube feeding, dialysis, blood glucose monitoring, 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. 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 Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.