Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on November 18, 2019.
You asked the Plan to pay for the orthosis. 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on November 18, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) of the abdomen and pelvis.
You asked the Plan to pre-approve the CT scan. You say that the records provided support the need for the requested CT scan. The Plan denied your request. The Plan says that the clinical information provided describes a condition that supports imaging of a different body region than the one requested.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee is noted to have a history of renal cancer, for which she underwent a nephrectomy in 2018. A CT abdomen/pelvis was recently. The health plan approved imaging of the abdomen, but not the pelvis. Given a history of renal cancer, current renal insufficiency and obesity, which limits physical examination, it is reasonable to image the entire GU system to assure no new, recurrent or metastatic. 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 CT scan have been met. Therefore,
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc for the enrollee.
You asked the Plan to pre-approve Genvisc. You say that that this is medically necessary. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
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 Genvisc. Our reviewer says that Genvisc is not medically reasonable and necessary for the enrollee in this case. The provided medical records do not indicate that the enrollee has tried and failed Orthovisc and Monovisc or that they would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Genvisc.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe platelet rich plasma (P9020) provided on February 27, 2019 and September 30, 2019.You asked the Plan to pay forthe platelet rich plasma (P9020). You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the services are not covered by Medicare or the plan.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.You were referred for the platelet rich plasma (P9020)by a contract provider. The file does not show that the plan provided notice that the platelet rich plasma (P9020) would not be covered. There is no documentation showing that the provider gave notice to the enrollee that these services would not be covered. Under Medicare rules, this means the platelet rich plasma (P9020) is considered approved.Therefore, we decided that the Plan has to pay forthe platelet rich plasma (P9020) provided on February 27, 2019 and September 30, 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's goal is to be able to completely care for herself. The Plan denied your request. The Plan says the enrollee does not have complex conditions which require close supervision, and an intensive rehab team for 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 physician reviewer found that the enrollee requires physical therapy for mobility and endurance. There is no clear need for occupational therapy. There is no new identified significant impairing upper extremity condition. The enrollee's debility can be appropriately treated by progressing her mobility with the physical therapy treatments being provided. The enrollee is limited by the severity of her comorbid medical conditions. She 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 home health physical therapy visits.
You asked the Plan to pre-approve home health physical therapy. The Plan denied your request. The Plan says the enrollee is no longer homebound and has reached goals.
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 physical therapy. Our physician reviewer found that you are independent with transfers and ambulation. The records do not show that additional home health skilled therapy services are required to effectively provide treatment in order to improve your condition, or to establish a maintenance program to maintain your condition or prevent deterioration. The documentation does not reveal that you are still home bound. You are at a functional level that no longer requires home health skilled physical therapy. 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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 home health physical therapy visits.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the records do not indicate that the criteria for coverage of IRF care have 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 enrollee does not require the intensity of services provided at an IRF. 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 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 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that the services 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. 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 additional physical therapy 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 for debility, physical therapy (PT) is generally accepted as specific and effective therapy. Goals include reducing pain, restoring function, and educating regarding a home exercise program (HEP) prior to transition towards a home program. In this case, there is no indication prior PT has served to provide sustained, significant improvement in pain and/or function and there are no indications residual deficits could not be addressed via a home exercise program. Therefore, this request is deemed 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 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
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 IRF care is medically necessary. The Plan denied
your request. The Plan says the enrollee's conditions have been well-controlled at their current facility. The
Plan says that the enrollee does not require a higher level of care at this time.
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 enrollee does not require the intensity of services provided at an IRF.
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 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 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: 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing medication management, skin and O2 care, and daily therapy can be provided at a SNF. In this case, you are mostly standby assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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: Favorable

We decided that the Plan has to hold you harmless for the injection services provided by physician on August 6, 2019 minus any cost share requirement.You asked the Plan to pay for these injection services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the services received are not medically necessary.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.The plan follows these rules.You were referred and provided these injection services by physician. physician is a contract provider. The file does not show that the plan provided notice that these injection services would not be covered. Under Medicare rules, this means these injection services is considered approved by the plan. Therefore, we decided that the Plan has to hold you harmless for the injection services provided on August 6, 2019 minus any cost share requirement amounts. 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you need to be in a controlled environment. The Plan denied your request. The Plan says it is unlikely you will need a stay of greater than 25 days in an LTACH.
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 physician reviewer found that you are currently undergoing treatment at an acute care hospital (ACH) for a urinary tract infection with sepsis and bacteremia. You are not intubated/ventilated. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 10, 2019.
You asked the Plan to pay for the orthosis. 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 knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on June 12, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says documentation submitted did not include a detailed physician order.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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid  physician order for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on June 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve these services. You say that it would be hard to move around your home in a power wheelchair. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a power scooter is covered when specific criteria 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 these services. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the submitted physical therapy (PT) evaluation notes that you cannot safely use a power scooter in your home. The therapist states that the requested power scooter is not maneuverable within your home. The requested power scooter 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 a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea visual field assessment, with concurrent real time data analysis (0379T).You asked the Plan to pre-approvethis service. You say that a visual field assessment is medically necessary.The Plandenied your request. The Plan says that the requested serviceis not considered medically reasonable or necessary.The Plan must follow Medicare rules. Medicare rules say that a visual field assessment (0379T) will be denied as not reasonable and necessary.The service at issue,visual field assessment, with concurrent real time data analysis is not listed under the "Indications and Limitations of Coverage"section of the LCDand is therefore not medically necessary. It is also listed in the LCA as notreasonable and necessaryand is not a covered benefit of Medicare or the Health Plan. 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-approvea visual field assessment, with concurrent real time data analysis (0379T).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that therapy will improve strength, and assist with getting back to your prior level of function. The Plan denied your request. The Plan says your services can be provided in the current long-term care setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our physician reviewer found that from a nursing perspective, you had stable vital signs, and was treated for pain. There are no identifiable skilled nursing service needs. Regarding rehab services, there are no therapy notes to document your current functional status or the need for skilled services. You do not require skilled nursing or therapy services on a daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.