Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves.
You asked the Plan to pre-approve radiofrequency ablation of the genicular nerves. You say that this service is medically necessary. The Plan denied your request. The Plan says the service is experimental/investigational.
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 radiofrequency ablation of the genicular nerves. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is considered experimental/investigational for your medical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation of the genicular nerves have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network provider.

You asked the Plan to pre-approve the office services. You say that this is the only provider that performs stabismus surgery. The Plan denied your request. The Plan says there is an in-network provider that can render the services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve budesonide/formoterol aerosol inhaler, for the enrollee.
You asked the Plan to pre-approve the inhaler. You say that this is a continuation of care and it has helped with maintaining the enrollee's asthma. The Plan denied your request. The Plan says budesonide/formoterol aerosol inhaler is a self-administered drug. The Plan states the enrollee does not have pharmacy (drug) benefits administered by the Health Plan. The Plan states the enrollee does have coverage through another insurance.
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 budesonide/formoterol aerosol inhaler, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth visit provided on May 25, 2021.

You asked the Plan to waive the copayment for a telehealth visit. You say that you feel that you should not owe a copayment because it was not an in office visit. 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 $15 copayment for office visits, including telehealth services. 

You have been asked to pay a $15 copayment for a telehealth visit. A telehealth 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 for a telehealth visit provided on May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee meets Medicare criteria for acute inpatient rehabilitation and will benefit from this level of care that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's condition; the enrollee does not meet the requirements.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on review of the available records, the enrollee with an ankle fracture does not meet Medicare coverage criteria for an IRF admission. Based on the current medical stability and lack of
medical complexity, there is no need for a physical medicine and rehabilitation physician, supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no documented skilled nursing needs. The documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The enrollee will not be able to tolerate the intensity of therapies in an IRF. An IRF admission is not medically necessary based on lack of current medical complexity and lack of skilled nursing needs. While she may benefit from physical therapy and occupational therapy, the enrollee's therapy needs can be addressed at a lower intensity level such as 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care services from October 5, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care services. You say that continued inpatient care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for continued inpatient psychiatric care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient psychiatric care services. Our reviewer says that continued inpatient psychiatric care services are not medically necessary at this time. Our physician reviewer found this enrollee did not require inpatient mental health treatment beyond the dates in question as he was not a danger to himself or others and did not have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. Based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of October 5, 2021, forward and could be treated in a lesser restrictive 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 inpatient psychiatric care services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care services from October 5, 2021, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says the records do not indicate that there are significant or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing medication management, skin care, labs, vital signs monitoring, and daily therapy can be provided at a lesser 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 in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that 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 encephalomalacia, hypotension and shoulder pain after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a heavy-duty power wheelchair (K0825) and accessories (E0973, E2361, E1028).

You asked the Plan to pay for a heavy-duty power wheelchair and accessories. You say that this is necessary because the enrollee needs a wider seat. The Plan denied your request. The Plan says the enrollee does not meet the weight requirement for the requested chair.

The Plan must follow Medicare rules. Medicare rules say that a heavy-duty power wheelchair is covered for a beneficiary weighing 285 - 450 pounds.

We looked at the file and Medicare rules. The records show that the enrollee does not weight between 285 and 450 pounds. Based on this information, we decided that Medicare rules for coverage of a heavy-duty power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pay for a heavy-duty power wheelchair (K0825) and accessories (E0973, E2361, E1028).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-therapeutic continuous glucose monitor (CGM) (A9277 and A9276).
You asked the Plan to pre-approve a non-therapeutic CGM. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says non-therapeutic CGM's are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a non-therapeutic CGM have not been met. Specifically, the requested CGM device does not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a non-therapeutic continuous glucose monitor (CGM) (A9277 and A9276).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for a gym membership (S9970)
for the 2021 allowance benefit.
You asked the Plan to reimburse you an additional amount for a gym membership. You say that you should be
reimbursed because it is a gym membership, and it is money that you have already paid. The Plan denied your
request. The Plan says you provided a receipt that shows a partial proof of payment for your request.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the
plan reimburses you up to $150 each calendar year towards your cost for membership in a qualified health club
or fitness facility.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can only reimburse
you when valid receipts are submitted. The Plan received a receipt for $105.25 for a gym membership from
January 2021 to April 2021. The Plan previously reimbursed you $100. You filed an appeal for an additional
reimbursement of $50. The Plan will reimburse an additional amount of $5.25. Please note, receipts for the
remaining $44.25 were not submitted. The Plan's rules for any further reimbursement for gym benefits have
not been met. Therefore, we decided that the Plan does not have to reimburse you an additional amount for a
gym membership (S9970) for the 2021 allowance benefit.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Skilled Nursing Facility services billed with GAGD1 x 4 days on February 26, 2020, through February 29, 2020.
You asked the Plan to pay for the  Nursing Facility services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says The Nursing Admission Functional Assessment Section GG forms received do not include the clinician signature and cannot be used to support assessment coding.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Nursing Facility services have not been met. Specifically, the record did not include documentation regarding the Nursing Admission Functional Assessment to verify the physician signature.
Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility services billed with GAGD1 x 4 days on February 26, 2020, through February 29, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from July 20, 2020, to July 26, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were admitted due to the coronavirus and thought the copayments were waived. 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 $225 copayment for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from July 20, 2020, to July 26, 2020. The record shows that this stay fell outside of the coronavirus waiver timeframe. Therefore, you are responsible to pay a $225 (copayment) for
days 1-6 (July 20, 2020, to July 25, 2020). The total amount you owe is: $1,350. You have been asked to pay the total copayment amount of $1,350 for an inpatient hospital stay. 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 from July 20, 2020, to July 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because you will be discharged soon and are unable to walk with no one to look after you. The Plan denied your request. The Plan says your needs may be met in a lower level of care.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled services on a daily basis and you do not meet the severity of illness or intensity of service criteria for an inpatient basis in an SNF. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services do not meet the requirements for approval.
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 that there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve NPWT electrical pump, stationary or portable (CPT code E2402), for the enrollee.

You asked the Plan to pre-approve the NPWT. You say that the DME is necessary. The Plan denied your request. The Plan says NPWT is not medically necessary after four (4) months have elapsed using a NPWT pump in the treatment of the most recent wound.

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 NPWT. Our physician reviewer found the last notes received for this member show that the wound is pink and had scant serosanguineous drainage 5x2.5x0.5. The LCD L33821 states that the NPWT is not medically necessary after 4 months have elapsed using a NPWT pump in the treatment of the most recent wound. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 

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 NPWT have not been met. Therefore, we decided that the Plan does not have to pre-approve NPWT electrical pump, stationary or portable (CPT code E2402), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office services (CPT code(s) 99204 and 99214) to be provided by an out-of-network provider at an in-network rate.

You asked the Plan to pre-approve the office services. You say that this doctor is the best in the area. The Plan denied your request. The Plan says what is being denied is the in-network cost sharing with this out-of-network provider.

The Plan must follow Medicare rules. 

We looked at the file and Medicare rules. Review of the file shows that you are requesting to see an out-of-network provider. Your Plan allows you to see out-of-network providers at an out-of-network rate. There are in-network providers that can provide the services; therefore, if you use this out-of-network provider you will have to pay the out-of-network cost-share. Therefore, we decided that the Plan does not have to pre-approve the office services (CPT code(s) 99204 and 99214) to be provided by an out-of-network provider at an in-network rate.