Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve conscious sedation, initial 15 minutes (D9239), and conscious sedation, additional 15 minutes (D9243).
You asked the Plan to pre-approve the conscious sedation services. You say that the services should be covered. The Plan denied your request. The Plan says conscious sedation services are not listed as covered dental services.
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 conscious sedation services are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pre-approve conscious sedation, initial 15 minutes (D9239), and conscious sedation, additional 15 minutes (D9243).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 29, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. The submitted documentation does not contain medical records from the non-contract provider. Without records, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fitness program benefits with a non-Plan provider.
You asked the Plan to pre-approve fitness program benefits with a non-Plan provider. You say that you would
like the Plan to reconsider their denial. The Plan denied your request. The Plan says you are covered for the
services requested under the Plan's supplemental fitness program benefit; however, you must receive these
services from the Plan provider.
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 covers gym benefits
only when provided from the Plan's fitness benefit provider.
The Plan's rules for coverage of gym benefits have not been met because you are asking to receive fitness
benefits from a non-Plan provider. Therefore, we decided that the Plan does not have to pre-approve fitness
program benefits with a non-Plan provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of an indwelling ureteral stent (52356) provided on April 26, 2021.

You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to the service provided.

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 your annual deductible is $1,000. This is the amount you must pay out-of-pocket before the Plan will pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Once you have paid your deductible, the Plan will begin to pay their share of the costs for covered medical services and you will pay your share (your copayment and coinsurance amount) for the rest of the calendar year. After you pay your $1,000 deductible, you pay a $275 copay for each Medicare covered outpatient surgery at a hospital outpatient facility. 

You have been asked to pay a $440.67 deductible for the outpatient surgery provided as you had not previously met the annual deductible. 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. Additionally, it appears from the documentation provided, that you have issued payment to the provider of service on May 21, 2021 for this deductible amount billed. As such, no additional payment would be required. Therefore, we decided that the Plan does not have to waive the deductible for the cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of an indwelling ureteral stent (52356) provided on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 standard power wheelchair (K0813) with
battery (E2365).

You asked the Plan to pre-approve a Group 1 standard power wheelchair with battery. You say that the
requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for power
mobility devices have not been met.

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 shows that your condition can be improved by a walker, cane, or manual wheelchair. 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 1 standard power wheelchair (K0813) with battery (E2365).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on February 25, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says screening tests 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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power mobility device provided on May 7, 2021.

You asked the Plan to pay for this equipment. You say that the Plan should cover the cost of this power wheelchair. The Plan denied your request. The Plan says Medicare coverage criteria for a power wheelchair are not met and you did not have prior authorization for this equipment.

The Plan follows Medicare rules. Medicare has specific coverage criteria for power wheelchairs. The Plan contract requires prior authorization for this type of equipment. The provider and your physician have indicated the required Medicare evaluation was not done. The Plan did not authorization this equipment. Therefore, we decided that the Plan does not have to pay for a power mobility device provided on May 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two home health skilled nursing visits.
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 medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the home health record dated October
6, 2021 states you have right shin lesions with no measurements taken. The records do not show you have any
skilled nursing needs, such as complex wound care. You have a caregiver who is capable of providing your
wound care needs. The home health services are 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 two home health skilled nursing 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 you need intensive rehabilitation services to recover fully and would not receive the same level of care at a nursing facility. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You do not have complex rehabilitation or medical needs. Your care can be provided safely 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 special benefits for the chronically ill (S9986).

You asked the Plan to pre-approve the special benefits for the chronically ill. You say that the special benefits are 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. These benefits are not medical in nature and are not eligible for coverage under Medicare rules. The plan's rules apply in this case. The plan covers this benefit for an enrollee with a covered diagnosis that is at high risk for hospitalization or adverse health outcomes. 

We looked at the file, and Medicare rules. The form to request these benefits shows that the enrollee does not have a covered diagnosis. Based on this information, we decided that Medicare rules for coverage of the special benefits for the chronically ill have not been met. Therefore, we decided that the Plan does not have to pre-approve special benefits for the chronically ill (S9986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myomo MyoPro powered upper extremity range of 
motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, 
all components and accessories, custom fabricated (CPT code L8702), for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that since the enrollee's stroke, the enrollee tried and 
failed standard rehabilitation techniques, including physical therapy, occupational therapy, and modalities such 
as static bracing. The Plan denied your request. The Plan says your request is not medically necessary because 
the medical records provided for review do not cite failure of specific modalities and/or devices used in the 
enrollee's rehabilitation. The Plan states the medical records do not document that this device meets but does 
not exceed the enrollee's needs nor do they indicate that the device is appropriate with respect to duration and 
frequency of therapy. The Plan states peer reviewed literature considers the use of robotic therapy for upper 
and lower extremity stroke rehabilitation investigational in nature with no long-term outcome data or 
continuation rate data at this time. The Plan states the enrollee has spastic paralysis of their arm, noted within 
the medical records, which is a contraindication of use of this device. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided, and current clinical guidelines, there is no 
documentation that the Myomo MyoPro powered upper extremity range of motion assist device at issue in this 
case meets Medicare criteria for medically reasonable and necessary. 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. In addition, the provided medical records document 
left shoulder subluxation which may be a contraindication to use of the device. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Myomo MyoPro powered upper extremity range of motion assist device, elbow, wrist, hand, 
finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom 
fabricated (CPT code L8702), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 additional physical therapy visits.
You asked the Plan to pre-approve 18 additional physical therapy visits. You say that the records provided support the need for continued physical therapy treatment. The Plan denied your request. The Plan says the enrollee has not made significant progress with therapy.
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 18 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 there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the patient's condition. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. Based on the available records no justification is provided for further physical therapy beyond the 55 visits already provided plus the two additional visits recently approved to establish a home exercise program. Further utilization of the home exercise program appears appropriate at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 18 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 18 additional physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac rehabilitation visits with an out of network (OON) provider.
You asked the Plan to pre-approve the OON cardiac rehabilitation visits. You say that the enrollee is unable to drive to Tacoma for his care due to the severity of his medical conditions. You say that the care being requested is medically necessary and available in Gig Harbor where the enrollee resides. The Plan denied your request. The Plan says there is no medical necessity to authorize an outside provider when the enrollee's care can be provided by an in-network provider who is well within the Medicare network adequacy guidelines.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The plan contract says that enrollees must use contract providers. The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from the enrollee's home who can provide the OON cardiac rehabilitation visits. Under Medicare rules, this means that contract providers are accessible to the enrollee.
Therefore, we decided that the Plan does not have to pre-approve cardiac rehabilitation visits with an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve the acute inpatient hospital care. You say that inpatient care following
surgery is medically necessary. The Plan denied your request. The Plan says the criteria for inpatient care have
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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found that the enrollee is medically stable. There is no specific indication for an
inpatient admission for the proposed elective surgery. The proposed procedure is not on the inpatient only list.
The review indicates that the record does not show that at the time of inpatient admission the admitting
physician reasonably expected that the patient's necessary hospital care (including earlier emergency
department and/or observation care) would span two midnights.
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 acute inpatient hospital care have not been met. Therefore, we decided that
the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on November 30, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization.
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 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 physician services provided to the enrollee on November 30, 2020.
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 admission to an IRF are not met. Your needs can be met in a lower 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 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.