Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thirty (30) additional physical therapy (PT) visits
(97139).
You asked the Plan to pre-approve 30 additional PT visits. You say that the requested additional PT visits are
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not
meet criteria.
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 30 additional PT 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 you do not meet coverage criteria for the requested
additional physical therapy visits beyond the number received so far. There are no clinical details of the extent
of your neck pain to support the medical necessity for the therapy sessions. The requested services are not part
of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required
to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further
deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 30 additional PT visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve thirty (30) additional physical therapy (PT) visits (97139).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional accessories for a prosthetic leg (L5828, L5845, L5848, L5656) for the enrollee.  You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says there is no reason given for why this is 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 the accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed the enrollee's medical need, as the treating medical provider physician assistant documentation does not support that the enrollee requires a microprocessor knee over a standard mechanical K3 knee. Additionally the ability to use additional features of a phone app for the knee is a convenience item and also exceeds the enrollee's medical need and is not 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 the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional accessories for a prosthetic leg (L5828, L5845, L5848, L5656) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a urinary catheter and supplies provided
on June 4, 2021.
You asked the Plan to waive the coinsurance for the catheter and supplies. You say that you were advised that
the supplies would be fully covered. The Plan denied your request. The Plan says the correct coinsurance was
applied.
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 20%
coinsurance for durable medical equipment (DME), including catheter supplies.
You have been asked to pay $83.10, which is 20% of the allowed amount for the catheter and supplies
($415.50 allowed amount x 20% coinsurance = $83.10). The catheter and supplies fall within the Durable
Medical Equipment (DME) and Related Supplies 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
coinsurance for a urinary catheter and supplies provided on June 4, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lucentis 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 step therapy guidelines were not followed.

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 the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found it is documented that the enrollee received Avastin on 1/4/22. it is not documented that there was treatment failure with Avastin. The documentation does not support that Avastin would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 

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 Lucentis for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
September 27, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were not advised that the
provider was doing a comprehensive exam that would exceed your frequency limits. The Plan denied your
request. The Plan says this service exceeds the frequency limitation in your benefit 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, comprehensive oral evaluation
(D0150) is limited to one procedure every three plan years. The record shows that you received a
comprehensive oral evaluation (D0150) on January 25, 2021 and your comprehensive oral evaluation (D0150)
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive
oral evaluation (D0150) provided on September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay would greatly help your health and assist
with your mobility. The Plan denied your request. The Plan says the stay is not medically necessary based on
IRF criteria. The Plan states you could review alternate settings if requested such as skilled nursing facility,
outpatient setting or home health 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 the health plan's denial should be upheld. You do not require the intensity of services
provided at an IRF. Specifically, you are not shown to be able to tolerate fifteen (15) hours per week of
rehabilitative services with 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the enrollee needs help with walking, performing
basic functions, using the bathroom, getting in, and out of bed. You state the enrollee believes you are at a high
fall risk. The Plan denied your request. The Plan says the stay 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found at the time of discharge from the hospital the
enrollee had stabilized medically. The enrollee did not require any skilled nursing or rehabilitation services on
a daily basis at an inpatient level of care. The enrollee was not expected to make measurable gains within a
reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or
self-care tasks. The enrollee did not require skilled therapy to establish a safe and effective maintenance
program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF
level of care at the time of discharge from the hospital. The enrollee did not have any parental medications,
complex wound care or nutrition given via a feeding tube. The enrollee was medically stable without any acute
exacerbations of chronic medical problems. The enrollee's physical function is at or near their baseline and the
enrollee can receive further services at a lower level of care. Admission to a nursing facility at a skilled level of
care for inpatient skilled services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction services provided on September 2, 2021.  You asked the Plan to pay for the services provided. You say that the appointment was a follow-up after surgery. The Plan denied your request. The Plan says the claim was processed correctly.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and the Plan's rules. Eye refraction services are covered as part of routine vision services. The information in the case file does not show that you were seen for a routine eye exam. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on September 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. The Plan
states the enrollee is receiving medically necessary acute and/or critical care. The Plan states the enrollee does
not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues
for which LTACH may offer a therapeutic advantage.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was admitted with altered mental status due to hypoxic respiratory
failure from Coronavirus (COVID-19) pneumonia. The record indicates that the enrollee remains critically ill
with a high risk of reintubation. The record indicates that the enrollee requires ongoing critical care services.
The enrollee continues to receive acute care services, and these have not been denied. The medical record does
not indicate that the enrollee requires services that they are not currently receiving but that would be available
at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be
recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound debridement provided by an out-of-network provider on July 21, 2021.

You asked the Plan to pay for the wound debridement. You say that units were billed over the max of 12 due to the extensive size of the wound. You say that the medical notes attached will show proof of wound and should be reviewed. The Plan denied your request. The Plan says services should be received from network providers. The Plan also says that any and all codes on this claim are denied and previous payments to this provider are subject to recoupment.

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 wound debridement provided by an out-of-network provider on July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair, group 3 heavy duty, multiple 
power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (CPT code K0862) and the 
accessories (CPT code(s): E2363, E1028, E1007, E0955, E1028, E1012, E2377, E2313, E2311, E2608).

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says you do not have a qualifying diagnosis causing mobility limitation for which the group 3 
power wheelchair (CPT code K0862) is medically needed.

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 the DME. Our physician reviewer 
found you do not have a Group 3 qualifying diagnosis for a Group 3 power wheelchair. You do not have a 
mobility deficit that impairs mobility related activity of daily living (MRADL) participation in the home. You 
are able to ambulate with a cane and September 30, 2021, physician note states, that you need no assistance 
with eating, bathing, dressing, getting around the house. You ambulate well, is a low fall risk, performs 
activities of daily living (ADLs). There is no evidence of spasticity, intermittent catherization use, or being a 
high risk for skin breakdown. You state the requested wheelchair if for community use. The documentation 
does not reveal that tilt and recline are medically necessary or that the request for Group 3 power wheelchair 
with multiple power options is medically necessary per the NCD and LCD.

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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient 
weight capacity 301 to 450 pounds (CPT code K0862) and the accessories (CPT code(s): E2363, E1028, 
E1007, E0955, E1028, E1012, E2377, E2313, E2311, E2608).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental office visit received on August 24, 2021.
You asked the Plan to pay for the dental office visit. You say that these services were due to a medical
procedure and not dental services. The Plan denied your request. The Plan says the services received are not a
covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental office visit received on
August 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 21, 2021, to August 1, 2021.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's hospital stay is denied.

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 July 21, 2021, to August 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
October 18, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you went to this dentist for an
oral evaluation after receiving poor service from an in-network dentist. The Plan denied your request. The Plan
says this service exceeds the maximum allowed per period.
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, comprehensive oral evaluation
(D0150) is limited to one procedure every three plan years. The record shows that you received a
comprehensive oral evaluation (D0150) on September 14, 2021 and your comprehensive oral evaluation
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation (D0150) provided on October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device, provided on August 26, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the CPAP device. You say that the items should be covered. The Plan denied your request. The Plan says this item was obtained out-of-network.

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 the continuous positive airway pressure (CPAP) device, provided on August 26, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299) and direct skilled nursing services of a licensed practical nurse (LPN) (G0300).

You asked the Plan to pre-approve the direct skilled nursing services of an RN and LPN. The Plan denied your 
request. The Plan says these 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 the direct skilled nursing services of an 
RN and LPN. Our reviewer says that the requested home health skilled nursing services are not medically 
necessary or reasonable. Our physician reviewer found you do not have documented skilled nursing needs.

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 direct skilled nursing services of an RN and LPN have not been met.
Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a registered 
nurse (RN) (G0299) and direct skilled nursing services of a licensed practical nurse (LPN) (G0300).