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

We decided that the Plan does not have to pre-approve disposable gloves for the enrollee.

You asked the Plan to pre-approve the gloves. You say that this is medically necessary. The Plan denied your request. The Plan says this would be considered a convenience item, primarily hygienic in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve disposable gloves for the enrollee.
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 fell, and it is medically necessary for you to
receive this rehabilitation to help with daily activities and regaining strength to live a normal life. The Plan
denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 treatment by multiple therapies, including either physical therapy
or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation
that you 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 acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
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 you do not treat with insulin. 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 continuous glucose monitor (CGM).
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 need IRF care. The Plan denied your request. The Plan says the criteria for an admission to an IRF are not met. Your care needs can be met in an alternate setting.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 you 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 acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown (D6790).

You asked the Plan to pre-approve the retainer crown. You say that you feel that the Plan's coverage is inadequate, and you do not have any alternatives to receiving these procedures. The Plan denied your request. The Plan says the maximum amount the Plan can pay for the 2021 plan year has been reached. The Plan also says that you are responsible for paying for services after the maximum has been reached.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan pays up to a maximum of $1,000 in dental benefits each year. The record shows that a pontic for tooth #14 and a retainer crown for tooth #13 were approved for coverage up to the allowed $1,000 benefit limit and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a retainer crown (D6790).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 27, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based
on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable wheelchair controller (E2377), controller harness (E2313), and related electronic connections (E2311), along with a stealth health adjuster and a back-up camera.

You asked the Plan to pre-approve the requested wheelchair components. You say that the requested items are necessary. The Plan denied your request. The Plan says the expandable controller exceeds the enrollee's medical need, and the camera and height adjuster are not primarily medical in nature.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Only items that are primarily medical in nature can be considered covered durable medical equipment. 

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 requested wheelchair components. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found The documentation does not reveal that the patient requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The patient's strength and function in the upper extremities supports that the patient can control any power options through their own individual switches. 

We looked at this physician's review, the file, and Medicare rules. We find that the receiver height adjustment feature and back-up camera do not directly treat your mobility issue/medical condition. As such, these components are not considered durable medical equipment and cannot be covered. Based on this information, we decided that Medicare rules for coverage of the requested wheelchair components have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable wheelchair controller (E2377), controller harness (E2313), and related electronic connections (E2311), along with a stealth health adjuster and a back-up camera.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient admission and hospital stay provided from
December 24, 2019, to January 5, 2020 by an OON provider.

You asked the Plan to pay for the inpatient admission and hospital stay. The Plan denied your request. The Plan
says the services were rendered by a non-participating provider, and the enrollee was referred by another nonparticipating
provider. The Plan also says that prior authorization was not 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 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 the inpatient admission and hospital stay provided
from December 24, 2019, to January 5, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).

You asked the Plan to pre-approve the orthotic device. You say that given that traditional rehab strategies had been tried and failed, the enrollee's family medicine specialist and family nurse practitioner referred her for myoelectric orthotic restoration. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out-of-network (OON) provider
.
You asked the Plan to pre-approve an outpatient surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says there are in-network providers available for these 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 an outpatient surgery to be provided 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 Group 2 heavy duty power wheelchair and
accessories.
You asked the Plan to pre-approve a Group 2 heavy duty power wheelchair (K0825) and accessories (E2361,
E0973). You say that you need the power wheelchair to be able to go to doctor appointments and get
medication. The Plan denied your request. The Plan says community use wheelchairs are not a covered benefit
under Medicare and an in-home evaluation is needed to determine mobility related activities of daily living.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
The file does not contain a home assessment. Also the item at issue in this appeal is for use outside of the
home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use only outside
the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided
that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections 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 there is mention of low back pain but it is not consistently axial as it radiates to the left thigh, and causes leg pain and numbness.

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 services.

Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a documented history of lumbar radiculopathy. There is radicular pain to the left thigh. Therefore, it is not medically necessary or reasonable for this enrollee to have the injections as requested. 

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 not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa 1 mg capsule for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is a Part D drug.

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 Vascepa 1 mg capsule for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence garments.

You asked the Plan to pre-approve incontinence garments. You say that these items are necessary and that you would like them to be covered. The Plan denied your request. The Plan says that these items are not covered
.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence garments.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurostimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied
your request. The Plan says a review of the medical records did not document one of the diagnostic indications.
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 stimulator. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee is noted to have a history of low back pain and knee pain. However, it is not clear
that this pain was refractory to all treatment modalities. The enrollee reported a 90% improvement with the use
of medication for low back pain. It was otherwise unclear from the records if she was a surgical candidate for
low back pain. In this setting, it cannot be said that this stimulator would be used as a "last resort."
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 stimulator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a neurostimulator for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair of a broken complete mandibular denture base
(D5511) provided on May 3, 2021.
You asked the Plan to pay for the repair of a broken complete mandibular denture base. You say that this
service was rendered by an in-network dentist because you were sure that you had dental benefits that would at
least help pay for the denture repair. The Plan denied your request. The Plan says this service is not a covered
benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the repair
of a broken complete mandibular denture base (D5511) provided on May 3, 2021.
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 for the enrollee's
condition. The Plan denied your request. The Plan says rules for IRF care have 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 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 the patient was admitted for confusion and resection of a frontal brain mass found to
be metastatic from known prostate cancer. Medical problems are stable. There are no complex nursing or
rehabilitation needs. The patient 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 a intensive,
multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient 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 acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. You say that the enrollee is ready to go for continued therapy. You say that the enrollee has significant orthostatic hypotension during standing activity during therapy. You also say that the enrollee has decreased responsiveness after walking only 6 feet and needs assistance walking after that. The Plan denied your request. The Plan says the requested SNF admission is not medically necessary.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of the most recent documentation submitted, the enrollee has not stabilized medically. The enrollee's endurance to work with therapy has decreased due to continued hypoxia and hypotension. The reviewer found that the enrollee does not require skilled nursing and/or skilled therapy services on a daily basis at this time. The reviewer found that the enrollee is not able to tolerate skilled therapy services in a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. Therefore, the reviewer found that an admission to a SNF for inpatient skilled rehab services is not medically necessary 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 SNF admission have not been met. Specifically, the file shows that the enrollee does not require skilled nursing or skilled therapy services on a daily basis at this time. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.