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.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH care to regain maximum/prior level of functioning. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.
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 patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered later when the patient is more stable and treatment is completed. 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: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the unna boot application provided on April 7, 2021. We decided that the Plan does not have to waive the copayment for the wound debridement provided on March 25, 2021 and the office visit provided on March 31, 2021 and April 14, 2021
You asked the Plan to waive the copayment for the wound debridement, office visits and unna boot application. You say that this was an open painful wound subject to trauma and infection that needed debridement to assess the healing process. You say that you want to know why the Plan is not paying. The Plan says that the copayment applied correctly to the wound debridement and unna boot application. The Plan also says that the office visits applied a copayment less than the standard $45 copayment.
We decided that the Plan has to reduce the copayment for the unna boot application provided on April 7, 2021.
The Plan says you must pay $201.16 for the unna boot application. The unna boot application was provided by a specialist during an office visit and is not considered a surgical service. The Evidence of Coverage clearly states you pay a $45 copayment for in-network specialist services. Therefore, we decided the Plan has to reduce the copayment for the unna boot application from $201.16 to $45.
We also decided that the Plan does not have to waive the copayment for the wound debridement provided on March 25, 2021 and the office visit provided on March 31, 2021 and April 14, 2021.
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 $360 copayment for surgery services at an in-network outpatient hospital and a $45 copayment for in-network specialist services. You are only being asked to pay a $15 copayment, which is less than the standard $45 copayment for each office visit. Therefore, we decided the Plan does not have to waive the copayment for the wound debridement provided on March 25, 2021 and the office visit provided on March 31, 2021 and April 14, 2021.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not
required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this
point, the enrollee's care needs are custodial and, as a practical matter, can be provided 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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the elbow supports (K0108) and stealth height adjustable receiver (K0108).

You asked the Plan to pre-approve the elbow supports. You say that please reconsider the documentation provided for the wheelchair and accessories that are medically necessary to meet the enrollee's current needs. The Plan denied your request. The Plan says duplicate services cannot be covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. In this case we have confirmed that the requested elbow supports (K0108) and the stealth height adjustable receiver is already included with approved items E1028 and E1007. Based on this information, we decided that Medicare rules for coverage of the elbow supports have not been met. Therefore, we decided that the Plan does not have to pre-approve the elbow supports (K0108) and stealth height adjustable receiver (K0108).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulsed radiofrequency ablation services.

You asked the Plan to pre-approve pulsed radiofrequency ablation services. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered as it will be performed.

The Plan must follow Medicare rules. Medicare rules say that there is insufficient evidence in the published medical literature to determine the safety and efficacy of pulsed radiofrequency ablation services. 

We looked at the file and Medicare rules. In this case, the requested procedure is pulsed radiofrequency ablation services and not eligible for coverage based on Medicare rules. Based on this information, we decided that Medicare rules for coverage of pulsed radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve pulsed radiofrequency ablation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627) with chair.
You asked the Plan to pre-approve a seat lift mechanism. You say that the enrollee does not have the strength to get out of a chair without assistance. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is not medically necessary.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. 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 seat lift mechanism. Our reviewer says that the requested item is not medically necessary in this case. Our physician reviewer found that the documentation does not reveal that the enrollee has severe arthritis of the knee or hip; and/or a neuromuscular disease. There is no objective gait or detailed neuromuscular physician examination in the submitted documentation. A seat lift is not likely to (a) effect improvement in the enrollee's condition; or (b) arrest or
retard deterioration in the enrollee's condition. The records do not show that the enrollee is completely incapable of standing from a chair in the home or that the enrollee has the ability to ambulate. 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 seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism (E0627) with chair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. Your needs can safely be met in the current inpatient rehabilitation facility and a transfer to a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
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 step therapy requirement is not met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has right knee
osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do
not show that the required drugs would be contraindicated or less effective; therefore, Gel-One is 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 Gel-One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on November 5, 2020, to November 7, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you saw on TV that Covid-19 charges would be waived. 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 $200 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.

You have been asked to pay a $200 copayment per day for days 1-2 for an inpatient hospital stay. The total amount you are being asked to pay is $400 ($200 x 2 days = $400). The correct copayment has been applied to the stay that was provided. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided by a participating provider on November 5, 2020, to November 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Group 1 Power Wheelchair.
You asked the Plan to pre-approve the Group 1 Power Wheelchair. You say that you would like
reconsideration because the requested wheelchair is medically necessary. The Plan denied your request. The
Plan says the member does not meet medical necessity criteria for the requested wheelchair and wheelchairs for
use outside the home are not covered.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 Group 1 Power Wheelchair. Our
reviewer says that the documentation indicates the member is waiting for accessible housing and it is unclear
about the details of this housing. The documentation does not indicate that the member's caregiver is unable to
adequately propel an optimally configured manual wheelchair. Our physician reviewer found the
documentation is not clear that the power wheelchair will significantly improve the member's ability to participate in MRADLs in the home. 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 Group 1 Power Wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve the Group 1 Power Wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. At this point, your care needs are custodial and, as a practical matter, can be provided 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Epidural Lysis of Adhesions (62264) provided September 24, 2020.

You asked the Plan to pay for the Epidural Lysis of Adhesions. You say that the services were medically necessary. The Plan denied your request. The Plan says the procedure is investigational and is non-covered under Medicare.

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 pay for the Epidural Lysis of Adhesions. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Epidural Lysis of Adhesions is experimental for the treatment of low back pain. More research is needed to show safety and efficacy of the procedure. 

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 Epidural Lysis of Adhesions have not been met. Therefore, we decided that the Plan does not have to pay for Epidural Lysis of Adhesions (62264) provided September 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically
necessary. The Plan denied your request. The Plan says additional PT is not medically necessary and does not
meet Medicare coverage criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 ten (10) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that based on review of the available records, the
enrollee does not meet CMS coverage criteria for the requested continued services by a PT for 10 more visits.
In the absence of documentation that shows her progress, the need for requested ongoing physical therapy
services cannot be justified. The enrollee had a hemorrhagic cerebrovascular accident (CVA) and with recent
hospitalization and she was still functioning at very low level after inpatient daily rehabilitation. The enrollee
had therapy with the approved 20 visits and requesting 10 more visits and the requested additional therapy
visits are not medically necessary for the enrollee's post stroke care. She is at least 8 months if not longer since
the stroke and at such low functional level described above, it is not expected that she would make significant
gains with the additional 10 visits.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553) provided April
13, 2021.
You asked the Plan to pay for the continuous glucose monitor supplies. You say that the continuous glucose
monitor supplies were medically necessary. The Plan denied your request. The Plan says the documentation
does not support the billed items.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain medical records which support medical necessity for the supplies provided in this case. The records do not document the ordering physician discussing the need for this equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553) provided April 13, 2021.