Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF provided from February 1, 2021, through February 28, 2021.

You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says the SNF services are 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 pay for SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on review of the available records, the enrollee did not meet the CMS coverage criteria for an SNF stay after February 1, 2021. The enrollee was stable after being treated for left humeral fracture getting occupational therapy services with no new medical problems, had no documented nursing needs and she was at high functional level and did not need daily skilled therapies in an inpatient setting. The SNF stay from February 1, 2021, through
February 28, 2021 was not medically necessary with daily therapies in an inpatient setting. Her selfcare needs were at a lower 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF provided from February 1, 2021, through February 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair initial inguinal hernia services coded 49505 provided on February 24, 2021.
You asked the Plan to pay for the repair initial inguinal hernia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are a duplicate
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 49505 is repair initial inguinal hernia, age 5 years or older; reducible. We find that CPT code 49505 is not supported in the medical record. Specifically, this is a duplicate claim to another claim billed by the same provider for the same date of service. The documentation supports that the services were only rendered once. This means this claim is a duplicate claim and is not payable. Based on this information, we decided that Medicare rules for coverage of the repair initial inguinal hernia services have not been met. Therefore, we decided that the Plan does not have to pay for the repair initial inguinal hernia services coded 49505 provided on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for surgical management of an infection of an artificial hip joint. She is now medically stable with no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. She does require
physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no compelling data to suggest that proton therapy is superior to or more beneficial than intensity modulated radiation therapy or image guided radiation therapy. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. The proton beam therapy is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
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 these services. You say that the provider is highly recommended. The Plan denied your request. The Plan says the services are available from network providers.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a back-up battery for a continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve these services. You say that you need the item due to loss of electricity. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a back-up battery for a continuous positive airway pressure (CPAP) device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says you have exhausted your skilled nursing bed days for the benefit period.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from March 28, 2021, through April 7, 2021 (10 days), April 9, 2021, through May 7, 2021 (28 days), May 17, 2021, through June 20, 2021 (34 days), June 26, 2021 through July 6, 2021 (10 days), and July 18, 2021, through August 2, 2021 (18 days). The Plan has covered 100 days of SNF care.
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Plus Aviva Plus 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 preferred providers.
The Plan must follow Medicare rules. The rules say that Plans may limit enrollees to preferred providers.
We looked at the file and Medicare rules. The requested service are not from a preferred provider with the Plan.
The services are available from the preferred providers. Therefore, we decided that the Plan does not have to
pre-approve Accu-Plus Aviva Plus test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodontal scaling and root planing provided on March 11, 2021.
You asked the Plan to pay for the prophylaxis and periodontal scaling and root planing. You say that you didn't go to the dentist until you had contacted the Plan for pre-approval. You say that you were told the service was covered and that the provider is in-network. The Plan denied your request. The Plan says the dentist is not a participating provider with the Plan.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodontal scaling and root planing provided on March 11, 2021.
Your complaint about the provider ripping off the government and seniors is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
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 disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found you were admitted to the hospital for surgery for a hip fracture after a fall. You are now medically stable with no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You may benefit from further therapy
but do not require an intensive therapy program in an IRF. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aducanumab.
You asked the Plan to pre-approve Aducanumab. You say that you believe this drug might be able to slow the member's dementia. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 Aducanumab. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is an 81-year-old woman with Alzheimer's dementia. It has been documented that the enrollee has been diagnosed with advanced disease. Treatment with Aducanumab should be initiated in patients with mild cognitive impairment or mild dementia stage of disease, as this is the population studied in clinical trials. There are no safety or effectiveness data on initiating treatment at later stages of the disease than were studied. Therefore, the documentation does not support that Aducanumab is safe and effective for this patient.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aducanumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Aducanumab.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the whipple surgery with an out-of-network provider.
You asked the Plan to pre-approve the whipple surgery. You say that the service is medically necessary. The Plan denied your request. The Plan says there are in-network providers who can 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 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 whipple surgery with an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
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 not covered.
The Plan must follow Medicare rules. Medicare rules say that RFA of the SI joint is not medically necessary. We looked at the file and Medicare rules. The requested services are RFA of the SI joint. These services are denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital after being found down with diagnoses of altered mental status, acute kidney injury, hypovolemic shock, and required right lower extremity fasciotomy. He continues to receive acute 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. The LTACH services are not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, one or more needles, without electrical stimulation, initial 15 minutes (97810) and infrared therapy (97026) provided September 16, 2020.

You asked the Plan to pay for the acupuncture services. You say that say the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this is a non-covered provider as the provider is a licensed acupuncturist, not a physician. Infrared therapy is not covered.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the health plan contract says that the person providing the acupuncture must be a physician licensed to perform the service. The provider is a licensed acupuncturist, not a physician. The records also do not document that this provider is supervised by any physician. Infrared therapy is not covered. Therefore, we decided that the Plan does not have to pay for acupuncture, one or more needles, without electrical stimulation, initial 15 minutes (97810) and infrared therapy (97026) provided September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair lift (E1399).
You asked the Plan to pay for a stair lift. You say that you have attached a copy of the cost of the stairlift which
has been paid in full. You are seeking reimbursement for the cost. You understand the reimbursement would be
minus the 20% which would be your responsibility. The Plan denied your request. The Plan says this item is
not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pay for a stair lift (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve massage therapy. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says services of a massage therapist are not covered by
Medicare or the Plan.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore,
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an all-lower extremity prostheses, flex-walk system or
equal (L5981).
You asked the Plan to pre-approve the replacement K3 foot. You say that the medical records provided will
show proof of medical necessity. The Plan denied your request. The Plan says the requested K3 foot exceeds
the enrollee's needs and does not meet Medicare criteria as reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the replacement K3 foot. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found based on the medical records provided there is no documentation that the enrollee
meets the requirements listed in the LCD/PIM for Medicare coverage of the K3 foot feature. Records indicate
the enrollee is using a walker or wheelchair for mobility. These assistive devices are not consistent with a K3
level of mobility. Records do not indicate a K2 foot would be inadequate for the enrollee's 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 replacement K3 foot have not been met. Therefore, we decided that the Plan
does not have to pre-approve an all-lower extremity prostheses, flex-walk system or equal (L5981).