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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee. You asked the Plan to pre-approve the LTACH services. You say that the member exceeds the CMS criteria for LTACH admission. The Plan denied your request. The Plan says that all services that would be provided in the LTACH are being provided already in the current acute care setting already approved. The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), and expandable controller with related electronic connection and harness (E2377, E2311, E2313) and matching wheel color inserts (K0108).
You asked the Plan to pre-approve the requested power wheelchair accessories. You say that this should be covered due to medical necessity. The Plan denied your request. The Plan says the power seat elevation feature and the wheel color inserts are not covered as they are not primarily medical in nature. There is also no medical needs for the power seating options to be controlled from the main joystick.
The Plan follows Medicare rules. Medicare rules say that DME items may be covered when they are reasonable and necessary. In order to be considered DME, the item must be primarily used for a medical purpose. Power seat elevation systems are not considered primarily medical in nature and are noncovered. In this case, we find that the power seat elevation system and the wheel color inserts are correctly denied due to not being primarily medical in nature. We also 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 an expandable controller and the related hardware. Our reviewer says that the requested expandable controller and related items are not considered medically reasonable and necessary. Our physician reviewer found the documentation does not support that there is a medical need to control the options on the power wheelchair through a joystick. There is not
documentation that the enrollee would be unable to use the individual switches for each powered seating component. 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 requested power wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), and expandable controller with related electronic connection and harness (E2377, E2311, E2313) and matching wheel color inserts (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lightweight wheelchair (K0003).You asked the Plan to pre-approvethe lightweight wheelchair. You say that you have a walker, but that your knee is bad and you are afraid you are going to hurt yourself. You say that you do not want to fall and have to go to the hospital, when this could be taken care of with the wheelchair.The Plan denied yourrequest. The Plan says the medical documentation shows that the enrollee is able to sufficiently perform activities of daily living in the home with the use of a walker, and not show that the enrollee can self-propel a standard wheelchair in the home. The Plan follows Medicare rules. Medicare rules say that lightweight wheelchairs are covered for certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Planwas correct in denying the request to pre-approve the lightweight wheelchair. Our reviewer says that the documentation does not show that the enrollee has a covered indication for the requested device. Our physician reviewer found the records indicate that the enrollee can ambulate with a walker. The records do not say that the enrollee cannot self-propel a standard weight manual wheelchair.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 lightweight wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea lightweight wheelchair (K0003).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy services (97140, 97530) and office visits (99203) provided by a chiropractor from February 14, 2020 to February 24, 2020.You asked the Plan to pre-approvephysical therapy services and office visits. You say that you were not told these services would not be covered.The Plan denied your request. The Plan says these services are not covered under Medicare or the Plan.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 pre-approvephysical therapy services (97140, 97530) and office visits (99203) provided by a chiropractor from February 14, 2020 to February 24, 2020.
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative
services and regular physician evaluation. The enrollee's care needs can be met at an alternate 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for electrocardiogram provided by a participating provider on February 19, 2020.
You asked the Plan to waive the copayment for electrocardiogram. You say that you went for your annual wellness visit. You say that you did not know that the provider proceeded with an electrocardiogram. The Plan denied your request. The Plan says the correct copayment has been applied to the services that were provided.
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 outpatient diagnostic tests/in-network/non-radiology diagnostic services. You have been asked to pay $18.23 which is less than your copayment amount of $20 for an electrocardiogram. An electrocardiogram falls within the outpatient diagnostic tests/in-network/non-radiology diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for electrocardiogram provided by a participating provider on February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for nurse practitioner services provided on October 3, 2018.

You asked the Plan to pay for the nurse practitioner services. You say that the hospital is considered an authorized provider and any service rendered by the house provider would also be considered in that authorization. The Plan denied your request. The Plan says that there is no authorization on file.

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. The Plan has not identified the network status of the hospital or if there was authorization for the facility on file. Therefore, we decided that the Plan has to pay for nurse practitioner services provided on October 3, 2018. 

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 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 enrollee does not meet criteria for the IRF admission.
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 enrollee does not meet criteria for the IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for treatment of COVID-19 pneumonia then discharged to a skilled nursing facility. She fell at the SNF and was readmitted for management of a head laceration after which she was discharged home. All chronic medical problems are stable. There are no complex nursing medical or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. Although there is a documented need for physical therapy services, there is no documentation of a need for intensive rehabilitation therapy. There is not a reasonable expectation that this 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fosaprepitant, Dexamethasone sodium phosphate,
Obinutuzumab, and Palonosetron hcl.
You asked the Plan to pre-approve Fosaprepitant, Dexamethasone sodium phosphate, Obinutuzumab, and
Palonosetron hcl. You say that you would like the plan to reconsider their denial The Plan denied your request.
The Plan says the requested drugs are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Fosaprepitant, Dexamethasone sodium
phosphate, Obinutuzumab, and Palonosetron hcl. Our reviewer says that the documentation does not support
that the requested drugs are medically reasonable or necessary. Our physician reviewer found you have
relapsed/refractory diffuse large cell b-cell lymphoma. The submitted documentation does not indicate any
toxicity with Rituximab. The requested use of Obinutuzumab is not FDA approved. The use is not supported by
any of the CMS approved compendia. Since the Obinutuzumab is not medically necessary, the requested antinausea
meds are not necessary or needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Fosaprepitant, Dexamethasone sodium phosphate, Obinutuzumab, and
Palonosetron hcl have not been met. Therefore, we decided that the Plan does not have to pre-approve
Fosaprepitant, Dexamethasone sodium phosphate, Obinutuzumab, and Palonosetron hcl.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested
home ventilator.
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
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says
that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found
coverage criteria for a home ventilator are not met. This enrollee has severe chronic obstructive pulmonary
disease, heart failure with reduced ejection fraction, and obstructive sleep apnea. The enrollee has not tolerated
the noninvasive interface for CPAP or BiPAP, so is unlikely to tolerate it for a noninvasive ventilator. There is
no arterial blood gas to document hypercarbia. Medicare does not cover a home ventilator when used as
BiPAP. Certain BiPAP devices are capable of providing the AVAPS-AE mode that has been ordered. A home
ventilator is not 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 a home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system for the enrollee.You asked the Plan to pre-approve the system. You say that this is medically necessary.The Plan denied your request. The Plan says the clinical information does not support that the criteria has 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 the system.Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore,the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 system have not been met.Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF system for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that 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 documentation does not support that the enrollee's nursing, medical and
rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation
care. The enrollee is generally medically stable and the documentation does not support that they have complex
medical issues that require acute rehab nursing care, or monitoring by an inpatient physical medicine and
rehabilitation (PMR) physician three times per week. While the enrollee may benefit from continuing physical
therapy (PT) and occupational therapy (OT), the documentation does not support that there is need for an
intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an
interdisciplinary approach to rehabilitation care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea BionessL300 Go Lower System, H200 Wireless Hand Rehabilitation System, and an L300 Go Thigh plus System.You asked the Plan to pre-approvea Bioness L300 Go Lower System, H200 Wireless Hand Rehabilitation System, and an L300 Go Thigh plus System. You say that the items are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 a Bioness L300 Go Lower System,H200 Wireless Hand Rehabilitation System, and an L300 Go Thigh plus System. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is a convenience item andnot supported for your condition(s) above aggressive home exercise, physical therapy, and standard electrical therapies (TENS). As such, this request is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of a Bioness L300 Go Lower System, H200 Wireless Hand Rehabilitation System, and an L300 Go Thigh plus System have not been met.Therefore, we decided that the Plan does not have to pre-approvea Bioness L300 Go Lower System, H200 Wireless Hand Rehabilitation System, and an L300 Go Thigh plus System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on January 15, 2020.You asked the Plan to waive the copayment for specialist services. You say that you never had a copayment before for this. The Plan denied your request. The Plan says the correct copayment has been applied.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/specialist. You have been asked to pay $8.98 which is less than your copayment amount of $20 for specialist services. Since specialist services were provided, the correct copayment has been applied. Specialist services fall within the physician/practitioner services/specialist benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for specialist services provided on January 15, 2020