Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 18, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on June 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from
August 27, 2021, through August 31, 2021.
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says the enrollee was admitted to the facility under Respite Care while the family went to a wedding, as they were not able to care for him during this time. Respite care is not a covered benefit under Medicare Advantage Part C plan. At no time was SNF level of care requested or denied.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for SNF services provided from August 27, 2021, through August 31, 2021.
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 SNF care is medically necessary. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81599) provided on October 21, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is a non-participating provider, and the member was referred by a non-participating provider. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services (81599) provided on October 21, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device.  You asked the Plan to pre-approve a MyoPro Motion G Orthotic device. You say that the requested MyoPro Motion G Orthotic device is medically necessary. The Plan denied your request. The Plan says the requested MyoPro Motion G Orthotic device 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 MyoPro Motion G Orthotic device. Our reviewer says that the requested MyoPro Motion G Orthotic device is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the requested MyoPro Motion G orthotic device meets Medicare criteria for the enrollee in this case. No records from the enrollee's treating provider document why the requested device is the most appropriate treatment for the enrollee's condition as opposed to treatment with other modalities. The provided records indicate the enrollee has a left shoulder subluxation and left upper extremity spasticity which may be contraindications to the use of the requested device.  In addition, current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment.  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 MyoPro Motion G Orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553).
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections, or have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient admission for a shoulder replacement.
You asked the Plan to pre-approve the inpatient admission. You say that the inpatient admission is medically necessary. The Plan denied your request. The Plan says inpatient coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. Our physician reviewer found the records do not show that the enrollee's care is expected to span more than 2 midnights.
The procedure at issue is not on the inpatient-only list. The service can be performed on an outpatient 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 the inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient admission for a shoulder replacement.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from March 17, 2020 to April 3, 2020.
You asked the Plan to pay for the services. You say that the adjustment should be reconsidered. The Plan denied your request. The Plan says that there was no signed documentation from a licensed nurse, speech therapist, occupational therapist, or physical therapist stating the usual functional status.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not make any specific argument as to which functional abilities are felt to be incorrectly scored. The plan has not provided enough evidence to claim that the assessment coding was not done correctly. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from March 17, 2020 to April 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee braces (L1851, L1843).
You asked the Plan to pre-approve knee braces. You say that the knee braces are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of the knee braces.
The Plan follows Medicare rules. Medicare rules say that knee braces are covered for a beneficiary who is ambulatory and has knee instability. Knee braces will be denied if there is only a subjective description of joint instability. 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 knee braces. Our reviewer says that the knee braces are not medically necessary at this time. Our physician reviewer found there is no evidence of true knee instability on a physical exam. The exam does not indicate pathological laxity with objective measurements of any laxity of the knee. There is no evidence of a recent surgery or injury to the knee. The patient is noted ambulatory but there is no evidence that the patient requires the requested knee brace. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee braces have not been met. Therefore, we decided that the Plan does not have to pre-approve knee braces (L1851, L1843).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on October 15, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pre-approve Percutaneous Vertebral Augmentation (PVA) for the enrollee.
You asked the Plan to pre-approve Percutaneous Vertebral Augmentation (PVA). You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of 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 Percutaneous Vertebral Augmentation (PVA). Our reviewer says that Medicare coverage criteria are not met.
Our physician reviewer found the documentation does not support that the enrollee in this case is symptomatic and is hospitalized with severe pain, or is non-hospitalized with moderate to severe pain (NRS or VAS =5) despite optimal non-surgical management (NSM) with one of the following: Worsening Pain or Stable to improved pain (but NRS or VAS =5) when 2 or more of the following are present: Progression of vertebral body height loss greater than 25% vertebral body height reduction, Kyphotic deformity or Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] greater than 17). Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Percutaneous Vertebral Augmentation (PVA) have not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous Vertebral Augmentation (PVA) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Laparoscopic Gastrojejunostomy (43633).  You asked the Plan to pre-approve the Laparoscopic Gastrojejunostomy. You say that this procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Laparoscopic Gastrojejunostomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has mild esophagitis and gastritis and has had some improvement over two weeks while taking proton pump inhibitors. The record indicates that medical therapy will be continued. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 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 Laparoscopic Gastrojejunostomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a Laparoscopic Gastrojejunostomy (43633).
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 you would like reconsideration because the requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the IRF 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for laboratory services provided on September 28, 2021.  You asked the Plan to waive the deductible for the laboratory services. You say that you feel that the lab charges should not apply to the deductible since they were a part of the annual physical. The Plan denied your request. The Plan says the correct amount was applied to your deductible.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $250 deductible which applies to certain items and services.  The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $250 deductible which applies to certain items and services.        This cost sharing is a contractual obligation that had not been met at the time the laboratory services were received on September 28, 2021. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a bilateral MyoPro 2 Motion G device.  You asked the Plan to pre-approve a bilateral MyoPro 2 Motion G device. You say that the requested bilateral MyoPro 2 Motion G is medically necessary. The Plan denied your request. The Plan says the requested bilateral MyoPro 2 Motion G 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 bilateral MyoPro 2 Motion G device. Our reviewer says that the requested bilateral MyoPro 2 Motion G is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the requested bilateral MyoPro 2 Motion G devices meet Medicare criteria for the enrollee in this case. Although records from the device vendor argue medical necessity of the device, no records from the enrollee's actual treating provider clarify why the requested device is the most appropriate treatment for the enrollee's condition. Records report shoulder subluxation and upper extremity spasticity which may be contraindications to use of the requested device. In addition, the device is of unproven long-term benefit for the enrollee's condition in the home environment.  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 bilateral MyoPro 2 Motion G device have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral MyoPro 2 Motion G device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Juvederm injections (J3490).
You asked the Plan to pre-approve Juvederm. You say that Juvederm is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Juvederm. Our reviewer says that Juvederm is not medically necessary. Our physician reviewer found the use of Juvederm is not supported for use in this setting by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Juvederm have not been met. Therefore, we decided that the Plan does not have to pre-approve Juvederm injections (J3490).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a bladder cancer screening (88120) provided on July 7, 2021.
You asked the Plan to pay for a bladder cancer screening. You say that this is supported in the records. The
Plan denied your request. The Plan says this is not a covered screening service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a bladder cancer screening, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for a bladder cancer screening (88120) provided on July 7, 2021.