Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of a modality to 1 or more areas and the therapeutic procedures provided on January 29, 2020.
You asked the Plan to pay for the application of a modality to 1 or more areas and the therapeutic procedures. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 the application of a modality to 1 or more areas and the therapeutic procedures provided on January 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for 294 units of enteral formula (B4153) provided to the enrollee from April 29, 2020 to May 28, 2020.
You asked the Plan to pay for the additional units. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedural Coding System (HCPCS) code B4153 (294 Units) remains not supported, as the submitted medical records do not support the units billed.
The Plan must follow 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 code "Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, May include fiber, administered through an enteral feeding tube, 100 calories = 1 unit." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the additional units. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found although it is reasonable for the enrollee to request a small number of units of enteral formula based on needs, 294 units appears excessive. Additional amounts may be requested at a later, if needed. Therefore, this request for 294 units of Peptamen will be considered not reasonable or medically necessary as submitted. 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 units have not been met. Therefore, we decided that the Plan does not have to pay for 294 units of enteral formula (B4153) provided to the enrollee from April 29, 2020 to May 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prostatic arterial embolization (PAE) procedure.
You asked the Plan to pre-approve the PAE procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is not medically necessary and is not recommended outside the context of clinical trials.
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 PAE procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found prostatic arterial embolization (PAE) is an experimental technique to treat symptomatic BPH. Very limited studies have demonstrated possible short-term safety and efficacy. The most recent AUA guidelines do not recommend this procedure outside of a clinical trial setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PAE procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the prostatic arterial embolization (PAE) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit and electrocardiogram (ECG) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit and ECG. You say that you want to see this provider because they were recommended to you. The Plan denied your request. The Plan says your primary care physician has stated that there are network providers available to provide 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 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 office visit and electrocardiogram (ECG) to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gastrointestinal wireless capsule measure.
You asked the Plan to pre-approve gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report (91112). You say that the enrollee needs this procedure. The Plan denied your request. The Plan says medical studies have not proven that the device is helpful for treatment of the enrollee's problem.
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 gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report (91112). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in the enrollee's case, no gastric emptying scan was provided nor referenced in available records as having been performed as a pre-operative study commensurate with the clinical suspicion of gastric dysmotility in the enrollee's setting of a very large hiatal hernia that may require surgical repair. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report (91112) have not been met. Therefore, we decided that the Plan does not have to pre-approve a gastrointestinal wireless capsule measure.
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. The Plan denied your request. The Plan says you do not require daily skilled nursing or rehab 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.

Continued services, were requested. 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 physician reviewer found that from a nursing perspective, you had stable vital signs, and your lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a maximal assist level for bed mobility and transfers. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for psychotherapy.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.

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 an out-of-network referral for psychotherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have waive the copayment for the office visit.
You asked the Plan waive the copayment for the office visit. You say that you would like the copayment removed. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $20 copayment for physician/practitioner services. You have been asked to pay a $20 copayment for the office visit. the office visit falls within the physician/practitioner 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 waive the copayment for the office visit.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the Watchman device.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee is able to take oral anticoagulation, so the criteria is not met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you have recurrent paroxysmal atrial fibrillation (PAF) and failed atrial fibrillation ablation and elevated CHA2DS2VASC score, which requires long term anticoagulation therapy. You have had recurrent skin tears with bleeding and slow wound healing requiring hospitalization and repeated visits to wound care clinics due to slow healing. Although not a major, life-threatening contraindication to anticoagulation, it is clear that apixaban long-term anticoagulation therapy has contributed to the recurrent wound issues, which as you continue to age, are likely to become more severe and even harder to heal. As more data has accumulated regarding real world use of the Watchman device, it is becoming clearer that it appears safe and effective with less long-term bleeding side effects than long-term anticoagulation. CMS provides for shared clinical decision making with regard to use of this device and consideration of relative contraindications to anticoagulation therapy and lifestyle issues for its use. Given the rather severe recurrent wound healing and bruising issues along with her active lifestyle, you have significant relative contraindications to continued apixaban use.

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 device have been met. Therefore, we decided that the Plan has to pre-approve the Watchman device.

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: Favorable

We decided that the Plan has to pre-approve the Freestyle Libre therapeutic continuous glucose monitor.

You asked the Plan to pre-approve the continuous glucose monitor. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that coverage criteria for continuous glucose monitor has not been met.

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. In this case, the request for medical records from the provider was not responded to by the Plan. The information we did receive concerned a different enrollee. We followed up several times but did not receive a response. Therefore, we decided that the Plan has to pre-approve the Freestyle Libre therapeutic continuous glucose monitor.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient hospital care.

You asked the Plan to pre-approve inpatient care. You say that it would be a danger to the enrollee's wellbeing if he is not able to continue receiving care. The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is correct, because the enrollee does not need to be in the hospital and his needs are custodial in nature.

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 inpatient care. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found palliative and comfort care has been recommended by the physician, and no further acute care services are planned. Continued inpatient services are not justified as a lower level of care would be sufficient to help organize comfort 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient hospital care.
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 enrollee meets admission criteria for LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

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 the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 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 One Touch Ultra Blue test strips.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from the Plan's preferred providers.
The Plan must follow Medicare rules. The rules say that Plans may limit enrollees to preferred providers for durable medical equipment and supplies. We looked at the file and Medicare rules. The requested services are One Touch Blue test strips. One Touch Blue is not a preferred provider with the Plan. Test strips are available from the Plan's preferred providers. Therefore, we decided that the Plan does not have to pre-approve One Touch Ultra Blue test strips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve panniculectomy and excess skin excision surgery.

You asked the Plan to pre-approve panniculectomy and skin surgery. You say that you cannot shower, walk properly, and are in pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no documentation of functional impairment due to panniculus and no documentation of skin condition caused by it.

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 panniculectomy and skin surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have lost weight and would like your panniculectomy to be revised due to excess skin. There are no recent medical records available for review. The provider has indicated that liposuction is an alternative as you have no achieved desired weight loss. The documentation of the discussion with your treating provider indicates that the requested service is cosmetic 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 panniculectomy and skin surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve panniculectomy and excess skin excision surgery.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 24 additional routine transportation trips.

You asked the Plan to provide 24 additional routine transportation trips. You say that you need transportation to attend wound care treatments. The Plan denied your request. The Plan says you have 2 trips remaining for 2021.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have almost exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide 24 additional routine transportation trips.
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 enrollee needs LTACH care. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct.

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 the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 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.