Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
You asked the Plan to pre-approve home health skilled nursing services. You say that the services are needed since you still have an open wound that you need assistance with. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health skilled nursing services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for you. The wound appears to be minimal as of the latest record provided with a treatment that does not require skilled nursing 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 home health skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on September 13, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you did not receive the services and disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 $35 copayment per specialist visit. The medical records show that you received specialist services on September 13, 2019. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 fora specialist visit provided on September 13, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and serviceS.
You asked the Plan to pre-approve IRF care. You say that the enrollee will need 3 hours of therapy to adjust to his below knee amputation. The Plan denied your request. The Plan says the enrollee's medical condition appears stable, and there is no need for supervision by an inpatient rehab physician.
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 physician reviewer found that the enrollee is status-post right below-knee amputation. He has not been fitted with an immediate postoperative prosthesis. The enrollee's medical conditions appear stable. There is no complex wound care needs. He does not require medical oversight of his condition at an acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. There are limited short term goals of bed mobility and transfers with mobility at a wheelchair level at a supervision level of function or higher. He does not require an intensive rehabilitation therapy program. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. 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-approveSynvisc injections.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says you have not received 3 months of drug and non-drug therapy.The Plan follows Medicare rules. Medicare rules say that hyaluronan acid therapies are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine ifthe Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that you have osteoarthritis of the knee. You have not had recent physical therapy, and were just recently prescribed topical Voltaren gel. Youhad an intra-articular steroid injection. You have not had an adequate trials of conservative therapy such as Physical Therapy and NSAIDs. Therefore, request is deemed not medically reasonable or necessary at this point.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 services have not been met. Therefore, we decided that the Plan does not have to pre-approveSynvisc injections.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that two diagnostic injections are allowed per region irrespective of the joints injected with maximum of 2 joints allowable per session per region. No more than 4 therapeutic facet joint nerve blocks per year are reimbursable with 2 levels per region, per session after the appropriate documentation of 80% improvement with diagnostic blocks for the duration of the local anesthetic, and with a total relief and improvement of at least 50% of 6 weeks (including greater than 80% relief and greater than 50% relief). Two radiofrequency neurotomies per year involving 2 joints per region per session may be performed 2 times a year with appropriate documentation of relief with dual medial branch blocks, and 5 to 6 months of pain relief and functional improvement after a session. You can find this rule in the Local Coverage Determination for Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy, L34832 (eff 12/26/19).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a wireless capsule endoscopy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that there is continued hemorrhoidal bleeding that has not been successfully treated.
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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has unexplained anemia, requiring iron infusions. The documentation in the medical record does not support hemorrhoidal bleeding as the likely cause of the enrollee's anemia. Capsule endoscopy is a useful diagnostic tool in the evaluation of obscure GI bleeding. Most obscure GI bleeding is the result of lesions in the small intestine. This is a difficult area to image. Capsule endoscopy can visualize the entire mucosa, and can detect superficial lesions. This study has a high sensitivity for detecting lesions, and is considered a first-line test for obscure GI bleeding. 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 services have been met. Therefore, we decided that the Plan has to pre-approve a wireless capsule endoscopy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with
suspension sleeve (L1851, L2397) provided to the enrollee on July 22, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an X-ray and laboratory services and does not have to waive the coinsurance for Medicare Part B drug injections on August 9, 2019.
You asked the Plan to waive the copayments for an X-ray and laboratory services and to waive the coinsurance for Medicare Part B drug injections. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $40 copayment for an X-ray and a $5 copayment for lab tests. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received an X-ray on August 9, 2019. Therefore, you are responsible to pay $35, which is less than the $40 copayment. You received laboratory services on August 9, 2019. Therefore, you are responsible to pay the $5 copayment. You received Medicare Part B drug injections on August 9, 2019. The allowed amount is $1.26 and 20% of that is $0.26. The total amount you owe is $40.26. You have been asked to pay the total amount of $40.26 for an X-ray, lab services and Medicare Part B drug injections. An X-ray and laboratory services fall within the outpatient diagnostic tests and therapeutic services
and supplies benefit category. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 copayments for an X-ray and laboratory services and does not have to waive the coinsurance for Medicare Part B drug injections on August 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatmentwith an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have notbeen met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 10, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit arelikewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Outpatient surgery (47562) provided
August 14, 2019
You asked the Plan to waive the copayment for the outpatient surgery. You say that the copayment should be
waived. The Plan denied your request. The Plan says the correct cost sharing 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 $325
copayment for Outpatient surgery.
You have been asked to pay a $325 copayment for the outpatient surgery. 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 Outpatient surgery (47562) provided August 14, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoulder arthroscopy (29824).
You asked the Plan to pre-approve a shoulder arthroscopy. You say that the enrollee has persistence of discomfort deep in the shoulder joint that is worse with attempt at movement. The Plan denied your request. The Plan says this service is 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 a shoulder arthroscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not show pathology on imaging study that correlates with physical exam. More conservative measures are needed. Surgery not needed at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a shoulder arthroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a shoulder arthroscopy (29824).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee must try and fail the preferred drug, Retacrit first.
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 Aranesp. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with anemia and a diagnosis of stage 4 chronic kidney disease. The provided medical records do not indicate that the enrollee has tried and failed the required drug, Retacrit. The provided medical records do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4mg Ondansetron Tablets.
You asked the Plan to pre-approve the Odansetron. You say that the member has been experiencing episodic nausea and vomiting and you are requesting a drug that does not cause sedation. The Plan denied your request. The Plan says this drug is not covered under the member's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 4mg Ondansetron Tablets.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0652) and 2 garments to use with pneumatic compressor (E0667).
You asked the Plan to pay for a pneumatic compression device and garments. You say that this was denied as not medically necessary under Medicare rules and you respectfully disagree. The Plan denied your request. The Plan says the enrolle has not had the required 4 week trial of either E0650 or E0651 that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0652) and 2 garments to use with pneumatic compressor (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift recliner.
You asked the Plan to pre-approve the seat lift mechanism of a seat lift recliner. You say that you need a seat lift recliner to help you get up and get moving around the house. The Plan denied your request. The Plan says a recliner lift chair is not considered a covered piece of durable medical equipment.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. Medicare does not cover the upholstered portion of a seat lift chair. We looked at the file and Medicare rules. The medical records do not support the criteria. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism of a seat lift recliner have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift recliner.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the shoulder.
You asked the Plan to pre-approve the shoulder MRI. You say that the MRI is needed to rule out a rotator cuff tear. The Plan denied your request. The Plan says there is no shoulder exam and no evidence of a trial of conservative care.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 shoulder MRI. Our reviewer says that the requested imaging is not medically reasonable and necessary. Our physician reviewer found there is no documentation of a recent trial and failure of PT. There are no red flags for MRI. It is not needed at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shoulder MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the shoulder.