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

 We decided that the Plan does not have to waive the copayments for wound care services provided from May 13, 2021, to August 11, 2021.  You asked the Plan to waive the copayments for the wound care services. You say that you feel that you were overcharged for the services provided. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $295 copayment for surgery or other services provided at an outpatient hospital.     Procedure Copayment per EOC Actual Charges Tissue Removal - May 13, 2021 $295 $170.74 Tissue Removal - May 27, 2021 $295 $295 Tissue Removal - June 8, 2021 $295 $295 Tissue Removal - June 24, 2021 $295 $170.74 Tissue Removal - August 11, 2021 $295 $170.74 Total:  $1102.22  You have been asked to pay $1102.22 for the wound care services. The wound care services fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 copayments for wound care services provided from May 13, 2021, to August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group three power wheelchair and accessories.  You asked the Plan to pre-approve a group three power wheelchair and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says you do not have medical need for single power option included with K0856 group 3 power wheelchair. Also, E2377 and E2313 are not medically needed as there is no need to control more than two power options through the joystick.  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.   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 group three power wheelchair and accessories. Our reviewer says that the service is not medically necessary. Our physician reviewer found records do not document muscle spasticity, need for bladder catherization or high risk for skin breakdown.  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 group three power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group three power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand with single or double uprights, includes microprocessor, sensors, all components and accessories, custom-fabricated for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the requested device is considered experimental.  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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase  participation in bimanual activities.  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 a powered upper extremity range of motion assist device, elbow, wrist, hand with single or double uprights, includes microprocessor, sensors, all components and accessories, custom-fabricated 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 the enrollee has complex medical needs and is currently unable to walk; transfer to an IRF is medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the necessary services 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 the enrollee's 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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Promacta 50 mg tablet.  You asked the Plan to pre-approve Promacta. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  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 Promacta 50 mg tablet.   Benefits for Promacta may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repair to a power wheelchair.
You asked the Plan to pre-approve the repair. You say that this was damaged due to a collision caused by a
lack of maintenance on the wheelchair. The Plan denied your request. The Plan says this is not a covered
benefit.
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 repair. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found there were no medical provided documenting the nature of, or the cause of the
damage to the control unit of the wheelchair in order to certify that it meets the Medicare criteria for coverage
of repair.
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 repair have not been met. Therefore, we decided that the Plan does not have
to pre-approve repair to a power wheelchair.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing services provided from January 21, 2021, to February 25, 2021.  You asked the Plan to pay for the skilled nursing services. You say that you feel the services the enrollee received should be covered. The Plan denied your request. The Plan says the criteria for admission to a skilled nursing facility (SNF) have not been met.  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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 21, 2021, to February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (64447-59, 64450-59) provided on July 21, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not show that these procedures were distinct or independent from other services performed.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    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 pay for the services Our reviewer says that the use of modifier -59 is not supported by the records provided. Our physician reviewer found that both procedures in this case were reported with modifier -59. The procedure report documents "postoperative pain", therefore modifier -59 is not appropriate.   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 pay for the services (64447-59, 64450-59) provided on July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ilumya.  You asked the Plan to pre-approve Ilumya. You say that this is medically necessary. The Plan denied your request. The Plan says this use is not supported.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that the requirements for coverage of Ilumya have not been met. Our physician reviewer found the Plan requires a trial of Enbrel, infliximab, methotrexate and acitretin before they will approve the requested drug. Based on the medical records provided the patient has not tried and failed the required drugs. Methotrexate is not appropriate for the enrollee due to her alcohol use, but there is no indication that the plan's other required drugs would likely be less effective or have adverse effects for the patient.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging (92134), the intravitreal injection of a pharmacologic agent (67028), and the aflibercept injection (J0178) rendered by the out-of-network (OON) provider on August 20, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging (92134), the intravitreal injection of a pharmacologic agent (67028), and the aflibercept injection (J0178) rendered by the out-of-network (OON) provider on August 20, 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 you cannot go home safely, and you need inpatient rehab to regain your strength. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing skilled therapy and nursing needs can be provided 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services requested are medically necessary. The Plan denied your request. The Plan says the enrollee's records do not document surgical evaluation or records show that the enrollee is not a surgical candidate.
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 physician reviewer found workup for back pain not complete. There is no surgical consult for back pain treatment 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 percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650),
for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466).  You asked the Plan to pre-approve the home ventilator. You say that this is to be used for the treatment of chronic obstructive pulmonary disease (COPD). The Plan denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 home ventilator. Our physician reviewer found a home ventilator is not medically necessary. You have COPD and were hospitalized with an exacerbation in September 2021. The medical records consist of progress notes from that admission; there is nothing more recent. There was mild carbon dioxide (CO2) retention on an arterial blood gas (ABG) obtained while the patient was acutely ill. You improved on BiPAP. There is no ABG obtained while you are awake and stable as an outpatient. If there is persistent hypercapnea, your needs could be met with BiPAP, at less cost to the patient. Certain BiPAP devices can provide the AVAPS mode. Medicare does not cover a home ventilator when used as BiPAP.  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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that none of your care is contingent on skilled daily therapy.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of elbow fracture and hip fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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.